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General NPI Number Information
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NPI Number | 1033624812
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Entity Type | Organization
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Legal Business Name | OXYCLEAN AMBULATORY OPIATE DETOX CENTERS LLC
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Dates
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Enumeration Date | 12/03/2017
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 415 S MAIN ST
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City | WAYNESVILLE
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State | OH
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Zip | 45068-9553
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Country | US
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Telephone | 513-897-7162
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Fax |
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Provider Business Mailing Address
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Address Line | 3195 DAYTON XENIA RD # 900-162
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City | BEAVERCREEK
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State | OH
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Zip | 45434-6390
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Country | US
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Telephone | 937-718-7677
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHARLES EDWARD RUSSELL
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Credential | MD
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Telephone | 937-718-7677
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number | 35050063
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License Number State | OH
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