Provider Demographics
NPI:1104071075
Name:MYLES BOYS RECOVERY, INC.
Entity type:Organization
Organization Name:MYLES BOYS RECOVERY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MS ICADC CCDP MHPP G
Authorized Official - Phone:501-265-0211
Mailing Address - Street 1:7101 W 12TH ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-2404
Mailing Address - Country:US
Mailing Address - Phone:501-265-0211
Mailing Address - Fax:501-265-0292
Practice Address - Street 1:7101 W 12TH ST
Practice Address - Street 2:SUITE 403
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-2404
Practice Address - Country:US
Practice Address - Phone:501-265-0211
Practice Address - Fax:501-265-0292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARD33222251B00000X
AR408-C251B00000X
AR1404251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management