Provider Demographics
NPI:1679331284
Name:30:17 RECOVERY
Entity type:Organization
Organization Name:30:17 RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCBROOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-215-0449
Mailing Address - Street 1:188 CARRIAGE HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3969
Mailing Address - Country:US
Mailing Address - Phone:731-215-0049
Mailing Address - Fax:800-418-1395
Practice Address - Street 1:188 CARRIAGE HOUSE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3969
Practice Address - Country:US
Practice Address - Phone:731-215-0049
Practice Address - Fax:800-418-1395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty