Basic Information
| Provider Information | |||||||||
| NPI: | 1740548155 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY RECOVERY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 964 N MARKET ST | ||||||||
| Address2: | PO BOX 464 | ||||||||
| City: | LISBON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444329363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304241468 | ||||||||
| FaxNumber: | 3304249844 | ||||||||
| Practice Location | |||||||||
| Address1: | 964 N MARKET ST | ||||||||
| Address2: | |||||||||
| City: | LISBON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444329363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304241468 | ||||||||
| FaxNumber: | 3304249844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2012 | ||||||||
| LastUpdateDate: | 04/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | BURTON | ||||||||
| AuthorizedOfficialFirstName: | MILLIE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3304241468 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1052 | OH | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 2864262 | 05 | OH | MEDICAID |