Basic Information
| Provider Information | |||||||||
| NPI: | 1003337734 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDWEST DETOX CENTER LLC | ||||||||
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| OtherOrganizationName: | OHIO DETOX CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10019 REISTERSTOWN RD FL 3 | ||||||||
| Address2: | |||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211173902 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1757 INDIAN WOOD CIR STE A | ||||||||
| Address2: | |||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435374009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662030308 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2017 | ||||||||
| LastUpdateDate: | 01/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | BUTLER | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF LCC | ||||||||
| AuthorizedOfficialTelephone: | 8176028218 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.