Provider Demographics
NPI:1962999359
Name:NATURAL STATE RECOVERY CENTER LLC
Entity type:Organization
Organization Name:NATURAL STATE RECOVERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:K
Authorized Official - Last Name:GORDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-319-7074
Mailing Address - Street 1:10025 OAKLAND DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72118-1942
Mailing Address - Country:US
Mailing Address - Phone:501-319-7074
Mailing Address - Fax:501-800-1007
Practice Address - Street 1:924 MAIN ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3818
Practice Address - Country:US
Practice Address - Phone:501-319-7074
Practice Address - Fax:501-800-1007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-20
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 261QR0405X
AR324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility