MEDICARE: RECOVERY STREET CENTRAL LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1598438616
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RECOVERY STREET CENTRAL LLC

Provider Business Mailing Address
First Line	:	107 WHITE ALLEN AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45405-4932
Country	:	US
Telephone Number	:	937-380-2418
Fax Number	:

Provider Business Practice Location Address
First Line	:	107 WHITE ALLEN AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45405-4932
Country	:	US
Telephone Number	:	937-380-2418
Fax Number	:

Authorized Official
Title or Position	:	CONSULTANT
Name	:	TERRY L HILL
Credential	:
Telephone Number	:	937-380-2418

Provider Enumeration Date	:	07/26/2021
Last Update Date	:	07/26/2021

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