Basic Information
| Provider Information | |||||||||
| NPI: | 1760151377 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERU OPERATING CO., LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 ASHWOOD DR STE 200 | ||||||||
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| City: | BLUE ASH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452412424 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3413 S WALLICK RD | ||||||||
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| City: | PERU | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469707915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134897100 | ||||||||
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| ProviderEnumerationDate: | 09/08/2021 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | ROSEDALE | ||||||||
| AuthorizedOfficialFirstName: | ISAAC | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5134897100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.