Healthcare Provider Details

I. General information

NPI: 1184687030
Provider Name (Legal Business Name): OAK RIDGE TREATMENT CENTER ACQ CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 PRIVATE ROAD 977 COUNTY ROAD 44 NORTH
PEDRO OH
45659
US

IV. Provider business mailing address

PO BOX 26456
INDIANAPOLIS IN
46226-0456
US

V. Phone/Fax

Practice location:
  • Phone: 740-534-1386
  • Fax: 740-534-1497
Mailing address:
  • Phone: 317-524-6360
  • Fax: 317-544-4355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number052002
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number052003
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number052004
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number052001
License Number StateOH

VIII. Authorized Official

Name: CHRIS JAGODITZ
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 317-524-6360