Basic Information
| Provider Information | |||||||||
| NPI: | 1598242281 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST RECOVERY CENTER, LLC | ||||||||
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| OtherOrganizationName: | OHIO TREATMENT 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 | ||||||||
| TelephoneNumber: | 4438396928 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4747 MONROE ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8334408648 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2018 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | COSTLEY | ||||||||
| AuthorizedOfficialFirstName: | JESSIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4438396928 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MIDWEST RECOVERY CENTER, LLC | ||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 01-7639 | 01 | OH | OHMAS STATE LICENSE | OTHER |