Provider Demographics
NPI:1538603345
Name:MLRC, INC.
Entity type:Organization
Organization Name:MLRC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERIM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:FUNKHOUSER
Authorized Official - Suffix:
Authorized Official - Credentials:CATC
Authorized Official - Phone:812-204-4324
Mailing Address - Street 1:71777 SAN JACINTO DR STE 102B
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4457
Mailing Address - Country:US
Mailing Address - Phone:812-204-4324
Mailing Address - Fax:
Practice Address - Street 1:71777 SAN JACINTO DR STE 102B
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4457
Practice Address - Country:US
Practice Address - Phone:812-204-4324
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder