| Full Name | |
|---|---|
| Speciality | Clinic/center - Rehabilitation, Substance Use Disorder |
| Location | 247 Cic Blvd, West Union, Ohio |
| Authorized Official Name and Position | Randy Spaulding (CREDENTIALING) |
| Authorized Official Contact | 5134672825 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
6460 Harrison Ave Ste 200 Cincinnati OH 45247-7958 Ph: (513) 941-4999 | 247 Cic Blvd West Union OH 45693 Ph: (513) 941-4999 |
| NPI Number | 1215659412 |
|---|---|
| Provider Enumeration Date | 09/14/2022 |
| Last Update Date | 12/28/2022 |
| Certification Date | 12/28/2022 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1215659412 | NPI | - | NPPES |
| 0313320 | Medicaid | OH | |
| 0078786 | Medicaid | OH |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0850X | Clinic/center - Adult Mental Health | (* (Not Available)) | Secondary |
| 261QR0405X | Clinic/center - Rehabilitation, Substance Use Disorder | (* (Not Available)) | Primary |
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