MEDICARE: INDIANA CENTER FOR RECOVERY OUTPATIENT SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center
3	324500000X	Substance Abuse Rehabilitation Facility
4	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1336848076
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIANA CENTER FOR RECOVERY OUTPATIENT SERVICES LLC

Provider Business Mailing Address
First Line	:	2925 10TH AVE N
Second Line	:
City	:	PALM SPRINGS
State	:	FL
Zip	:	33461-3000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 N SHORE DR STE 102
Second Line	:
City	:	JEFFERSONVILLE
State	:	IN
Zip	:	47130-3144
Country	:	US
Telephone Number	:	561-635-2400
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KIRILL VESSELOV
Credential	:
Telephone Number	:	561-305-0461

Provider Enumeration Date	:	03/02/2023
Last Update Date	:	05/16/2024

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