Organization
RE-CREATION RETREAT LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RANDY K SODERQUIST LCSW (OWNER AND CLINICAL DIRECTOR)
(435) 691-0856
Entity
Organization
Contact information
Practice address
455 SOUTH MAIN, FREDONIA, AZ 86022
(435) 691-0856
Mailing address
380 W LOS BARANCOS LN, P.O. BOX 61, KANAB, UT 84741-3311
(435) 691-0856
Taxonomy
Speciality
Code
Description
License number
State
320800000X
Mental Illness Community Based Residential Treatment Facility
Primary
BH-3895
AZ
324500000X
Substance Abuse Rehabilitation Facility
BH-3895
AZ
Other
Enumeration date
06/07/2012
Last updated
11/21/2012
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