Healthcare Provider Details

I. General information

NPI: 1013418599
Provider Name (Legal Business Name): EAST INDIANA RECOVERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 NW 5TH ST
RICHMOND IN
47374-1844
US

IV. Provider business mailing address

117 S DIXIE DR STE 3
VANDALIA OH
45377-2142
US

V. Phone/Fax

Practice location:
  • Phone: 937-416-5442
  • Fax: 765-935-0073
Mailing address:
  • Phone: 937-416-5442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL KOLODZIK
Title or Position: OWNER
Credential: MD
Phone: 937-825-6220