Healthcare Provider Details

I. General information

NPI: 1033624812
Provider Name (Legal Business Name): OXYCLEAN AMBULATORY OPIATE DETOX CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S MAIN ST
WAYNESVILLE OH
45068-9553
US

IV. Provider business mailing address

3195 DAYTON XENIA RD # 900-162
BEAVERCREEK OH
45434-6390
US

V. Phone/Fax

Practice location:
  • Phone: 513-897-7162
  • Fax:
Mailing address:
  • Phone: 937-718-7677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number35050063
License Number StateOH

VIII. Authorized Official

Name: DR. CHARLES EDWARD RUSSELL
Title or Position: PRESIDENT
Credential: MD
Phone: 937-718-7677