Basic Information
| Provider Information | |||||||||
| NPI: | 1730448614 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RECOVERY SERVICES NWO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 511 PERRY ST | ||||||||
| Address2: | |||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435122123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197829920 | ||||||||
| FaxNumber: | 4197842523 | ||||||||
| Practice Location | |||||||||
| Address1: | 511 PERRY ST | ||||||||
| Address2: | |||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435122123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197829920 | ||||||||
| FaxNumber: | 4197842523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2012 | ||||||||
| LastUpdateDate: | 05/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | BOND | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4197829920 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 2864593 | 05 | OH | MEDICAID |