| B. Riley Sober House | |
|
2121 W 117th St Cleveland OH 44111-1642 | |
| (216) 417-4831 | |
| Not Available |
| Full Name | B. Riley Sober House |
|---|---|
| Speciality | Counselor |
| Location | 2121 W 117th St, Cleveland, Ohio |
| Authorized Official Name and Position | Rafael Antonio Correa (FOUNDER) |
| Authorized Official Contact | 2164174831 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| B. Riley Sober House 2121 W 117th St Cleveland OH 44111-1642 Ph: (216) 417-4831 | B. Riley Sober House 2121 W 117th St Cleveland OH 44111-1642 Ph: (216) 417-4831 |
| NPI Number | 1417625666 |
|---|---|
| Provider Enumeration Date | 09/02/2021 |
| Last Update Date | 05/16/2023 |
| Certification Date | 05/16/2023 |
| Medicare PECOS PAC ID | 3870958671 |
|---|---|
| Medicare Enrollment ID | O20230501001904 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1417625666 | NPI | - | NPPES |
| 0454981 | Medicaid | OH |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | (* (Not Available)) | Primary |
| 175T00000X | Peer Specialist | (* (Not Available)) | Secondary |
| Provider Name | Ruth M Lukehart |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1528331360 PECOS PAC ID: 3870958689 Enrollment ID: I20230501002029 |
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