MEDICARE: JCORBITTLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility	2241108	OH

General Provider Information

NPI Number	:	1568845634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JCORBITTLLC

Provider Business Mailing Address
First Line	:	3688 WALES DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45405-1845
Country	:	US
Telephone Number	:	937-607-9170
Fax Number	:

Provider Business Practice Location Address
First Line	:	3688 WALES DRIVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45406-2439
Country	:	US
Telephone Number	:	937-607-9170
Fax Number	:

Authorized Official
Title or Position	:	SUPERVISER
Name	:	MS. BETTY JEAN WALLACE
Credential	:	LICDC
Telephone Number	:	937-422-4349

Provider Enumeration Date	:	07/07/2015
Last Update Date	:	07/27/2015

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