Healthcare Provider Details

I. General information

NPI: 1174132542
Provider Name (Legal Business Name): RECOVERY STREET CENTRAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 03/28/2021
Certification Date: 03/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 LINDEN AVE STE 185
DAYTON OH
45432-3040
US

IV. Provider business mailing address

4130 LINDEN AVE STE 185
DAYTON OH
45432-3040
US

V. Phone/Fax

Practice location:
  • Phone: 937-380-2410
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TERRY HILL
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 937-380-2418