MEDICARE: THE FREEDOM RECOVERY CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1063047538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE FREEDOM RECOVERY CENTER LLC

Provider Business Mailing Address
First Line	:	153 N DIXIE DR APT 14
Second Line	:
City	:	VANDALIA
State	:	OH
Zip	:	45377-2033
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 WHITE ALLEN AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45405-4932
Country	:	US
Telephone Number	:	937-540-5716
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	CONRAD M GOODE V
Credential	:	CDCA, CMS, QMHS
Telephone Number	:	937-540-5716

Provider Enumeration Date	:	03/05/2020
Last Update Date	:	03/05/2020

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