MEDICARE: HOMELAND ADDICTION TREATMENT CENTER LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1356020515
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOMELAND ADDICTION TREATMENT CENTER LLC

Provider Business Mailing Address
First Line	:	3505 E LIVINGSTON AVE STE G
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43227-2252
Country	:	US
Telephone Number	:	614-715-8216
Fax Number	:	614-715-8239

Provider Business Practice Location Address
First Line	:	3505 E LIVINGSTON AVE STE G
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43227-2252
Country	:	US
Telephone Number	:	614-632-1018
Fax Number	:

Authorized Official
Title or Position	:	SUPERVISOR
Name	:	KINGSLEY EYONG ENOW
Credential	:	NP
Telephone Number	:	614-715-8316

Provider Enumeration Date	:	07/14/2023
Last Update Date	:	04/19/2024

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