=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326567512
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAR REACH FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2017
-----------------------------------------------------
Last Update Date | 09/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 BEAR RUN LN STE B
-----------------------------------------------------
City | LEWIS CENTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43035-8299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-624-7001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 BEAR RUN LN STE B
-----------------------------------------------------
City | LEWIS CENTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43035-8299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLO
-----------------------------------------------------
Name | BRIAN DEAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-949-0287
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084A0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------