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General NPI Number Information
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NPI Number | 1932058369
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Entity Type | Organization
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Legal Business Name | ICR ADOLESCENTS OPERATING SUBSIDIARY, LLC
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Dates
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Enumeration Date | 01/27/2026
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Last Update Date | 01/27/2026
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Provider Practice Location Address
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Address Line | 215 W 4TH ST
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City | MISHAWAKA
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State | IN
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Zip | 46544-1917
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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 | 1209 N ORANGE ST
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City | WILMINGTON
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State | DE
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Zip | 19801-1120
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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 | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation 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 | 3245S0500X
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Taxonomy Name | Children's 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 | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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