MEDICARE: ICR OUTPATIENT OPERATING SUBSIDIARY, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0850X	Adult Mental Health Clinic/Center
2	324500000X	Substance Abuse Rehabilitation Facility
3	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1568311900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ICR OUTPATIENT OPERATING SUBSIDIARY, LLC

Provider Business Mailing Address
First Line	:	2925 10TH AVE N
Second Line	:
City	:	PALM SPRINGS
State	:	FL
Zip	:	33461-3000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	135 HOSPITAL LN
Second Line	:
City	:	TERRE HAUTE
State	:	IN
Zip	:	47802-4247
Country	:	US
Telephone Number	:	305-361-9115
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	DANIEL MOORE
Credential	:
Telephone Number	:	305-361-9115

Provider Enumeration Date	:	01/27/2026
Last Update Date	:	02/24/2026

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