Healthcare Provider Details

I. General information

NPI: 1821411273
Provider Name (Legal Business Name): NEW DESTINY TREATMENT CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6694 TAYLOR RD
CLINTON OH
44216-9201
US

IV. Provider business mailing address

6694 TAYLOR RD
CLINTON OH
44216-9201
US

V. Phone/Fax

Practice location:
  • Phone: 330-825-5202
  • Fax: 330-825-5113
Mailing address:
  • Phone: 330-825-5202
  • Fax: 330-825-5113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number34.005720
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT W. BOLOIS
Title or Position: CEO
Credential: PH.D., LICDC-CS
Phone: 330-825-5202