Healthcare Provider Details

I. General information

NPI: 1366992224
Provider Name (Legal Business Name): DECOACH TEAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CROWNE POINT PL
CINCINNATI OH
45241-5427
US

IV. Provider business mailing address

100 CROWNE POINT PL
CINCINNATI OH
45241-5427
US

V. Phone/Fax

Practice location:
  • Phone: 513-743-7628
  • Fax: 513-737-1107
Mailing address:
  • Phone: 513-743-7628
  • Fax: 513-737-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number StateOH

VIII. Authorized Official

Name: KIMBERLY BARROWS
Title or Position: PRESIDENT
Credential:
Phone: 513-818-5146