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General NPI Number Information
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NPI Number | 1063047538
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Entity Type | Organization
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Legal Business Name | THE FREEDOM RECOVERY CENTER LLC
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Dates
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Enumeration Date | 03/05/2020
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Last Update Date | 03/05/2020
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Provider Practice Location Address
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Address Line | 109 WHITE ALLEN AVE
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City | DAYTON
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State | OH
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Zip | 45405-4932
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Country | US
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Telephone | 937-540-5716
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Fax |
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Provider Business Mailing Address
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Address Line | 153 N DIXIE DR APT 14
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City | VANDALIA
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State | OH
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Zip | 45377-2033
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | CONRAD M GOODE V
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Credential | CDCA, CMS, QMHS
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Telephone | 937-540-5716
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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