Basic Information
| Provider Information | |||||||||
| NPI: | 1033608195 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDWEST DETOX CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OHIO DETOX CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1757 INDIAN WOOD CIR | ||||||||
| Address2: | |||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435374009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662030308 | ||||||||
| FaxNumber: | 8556866641 | ||||||||
| Practice Location | |||||||||
| Address1: | 1757 INDIAN WOOD CIR | ||||||||
| Address2: | |||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435374009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668060308 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2018 | ||||||||
| LastUpdateDate: | 03/14/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUTLER | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF LCC | ||||||||
| AuthorizedOfficialTelephone: | 8176028218 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MIDWEST DETOX CENTER LLC | ||||||||
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| NPICertificationDate: | 01/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 01-7617 | OH | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.