=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619211547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED RECOVERY SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2012
-----------------------------------------------------
Last Update Date | 08/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 SOUTH 4TH STREET
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-918-3330
-----------------------------------------------------
Fax | 614-918-3329
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 326 S HIGH ST STE 200
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43215-4525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-918-3330
-----------------------------------------------------
Fax | 614-918-3329
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-DIRECTOR
-----------------------------------------------------
Name | MS. AALIYAH FAUNTLEROY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-918-3330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 13363
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------