Provider Demographics
NPI:1407686512
Name:SAM RECOVERY HOUSE LLC
Entity type:Organization
Organization Name:SAM RECOVERY HOUSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FUAD
Authorized Official - Middle Name:ABDINOR
Authorized Official - Last Name:MOHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:ETC
Authorized Official - Phone:971-386-7444
Mailing Address - Street 1:16132 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-5439
Mailing Address - Country:US
Mailing Address - Phone:971-386-7444
Mailing Address - Fax:
Practice Address - Street 1:16132 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-5439
Practice Address - Country:US
Practice Address - Phone:971-386-7444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)