Provider Demographics
NPI:1962050989
Name:BRICK HOUSE RECOVERY
Entity type:Organization
Organization Name:BRICK HOUSE RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:D
Authorized Official - Last Name:COOMBS
Authorized Official - Suffix:
Authorized Official - Credentials:MPC
Authorized Official - Phone:801-350-1716
Mailing Address - Street 1:3663 N LAKEHARBOR LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-6913
Mailing Address - Country:US
Mailing Address - Phone:801-350-1716
Mailing Address - Fax:
Practice Address - Street 1:1020 LAND BANK ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-1809
Practice Address - Country:US
Practice Address - Phone:801-350-1716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-03
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty