MEDICARE: THE CREED OF RECOVERY, 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1578085239
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CREED OF RECOVERY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 243
Second Line	:
City	:	SUGAR GROVE
State	:	OH
Zip	:	43155-0243
Country	:	US
Telephone Number	:	614-404-6008
Fax Number	:

Provider Business Practice Location Address
First Line	:	551 E MAIN ST
Second Line	:
City	:	LANCASTER
State	:	OH
Zip	:	43130-3809
Country	:	US
Telephone Number	:	614-404-6008
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ANDRIA EVANS
Credential	:	CEO
Telephone Number	:	614-404-6008

Provider Enumeration Date	:	07/13/2017
Last Update Date	:	07/13/2017

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