Basic Information
| Provider Information | |||||||||
| NPI: | 1518562883 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRIGHTVIEW LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 ELSINORE PL STE 200 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452021459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138347063 | ||||||||
| FaxNumber: | 5138731567 | ||||||||
| Practice Location | |||||||||
| Address1: | 485 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451772174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138347063 | ||||||||
| FaxNumber: | 5138731567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2020 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5138347063 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRIGHTVIEW LLC | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0401X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
No ID Information.