Provider Demographics
NPI:1306484860
Name:EAGLECREST RECOVERY LLC
Entity type:Organization
Organization Name:EAGLECREST RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-813-5161
Mailing Address - Street 1:1101 SW COVENTRY BLVD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4325
Mailing Address - Country:US
Mailing Address - Phone:479-367-2691
Mailing Address - Fax:479-367-2899
Practice Address - Street 1:1106 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-5026
Practice Address - Country:US
Practice Address - Phone:479-367-2691
Practice Address - Fax:479-367-2899
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAGLECREST RECOVERY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-16
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder