Basic Information
Provider Information | |||||||||
NPI: | 1932166220 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FIVE COUNTY ALCOHOL/DRUG PROGRAM SERENITY HAVEN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 830 S CLINTON ST | ||||||||
Address2: |   | ||||||||
City: | DEFIANCE | ||||||||
State: | OH | ||||||||
PostalCode: | 435122758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4197829920 | ||||||||
FaxNumber: | 4197842523 | ||||||||
Practice Location | |||||||||
Address1: | 25212 US ROUTE 20 | ||||||||
Address2: |   | ||||||||
City: | FAYETTE | ||||||||
State: | OH | ||||||||
PostalCode: | 435219511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192373103 | ||||||||
FaxNumber: | 4192374044 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOND | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4197829920 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LICDC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 7111 | OH | X |   | Agencies | Case Management |   | 261QR0405X | 7111 | OH | X |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261Q00000X | 7111 | OH | X |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 07111 | 01 | OH | MACSIS UPI | OTHER |