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General NPI Number Information
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NPI Number | 1568311900
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Entity Type | Organization
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Legal Business Name | ICR OUTPATIENT OPERATING SUBSIDIARY, LLC
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Dates
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Enumeration Date | 01/27/2026
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Last Update Date | 02/24/2026
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Provider Practice Location Address
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Address Line | 135 HOSPITAL LN
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City | TERRE HAUTE
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State | IN
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Zip | 47802-4247
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Country | US
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Telephone | 305-361-9115
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Fax |
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Provider Business Mailing Address
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Address Line | 2925 10TH AVE N
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City | PALM SPRINGS
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State | FL
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Zip | 33461-3000
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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 | AUTHORIZED OFFICIAL
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Name | DANIEL MOORE
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Credential |
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Telephone | 305-361-9115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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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 | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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