Basic Information
| Provider Information | |||||||||
| NPI: | 1093772386 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIVE COUNTY ALCOHOL/DRUP PROGRAM IN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 S CLINTON ST | ||||||||
| Address2: | |||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435122758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197829920 | ||||||||
| FaxNumber: | 4197842523 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ALVORDTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435019763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199242029 | ||||||||
| FaxNumber: | 4199242061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BOND | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4197829920 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | IV | ||||||||
| AuthorizedOfficialCredential: | LICDC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 0559 | OH | X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0850X | 0559 | OH | X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 332900000X | 0559 | OH | X | Suppliers | Non-Pharmacy Dispensing Site |
ID Information
| ID | Type | State | Issuer | Description | 10998 | 01 | OH | MACSIS UPI | OTHER |