MEDICARE: CEDAR RECOVERY OTP, 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	261QM2800X	Methadone Clinic

General Provider Information

NPI Number	:	1598576019
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CEDAR RECOVERY OTP, LLC

Provider Business Mailing Address
First Line	:	5000 CROSSINGS CIR STE 103
Second Line	:
City	:	MOUNT JULIET
State	:	TN
Zip	:	37122-8591
Country	:	US
Telephone Number	:	615-553-1322
Fax Number	:	615-549-7044

Provider Business Practice Location Address
First Line	:	4409 CHAPMAN HWY STE W
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37920-4326
Country	:	US
Telephone Number	:	615-553-1322
Fax Number	:	615-549-7044

Authorized Official
Title or Position	:	CHIEF STRATEGY OFFICER
Name	:	PAUL STEPHEN TRIVETTE
Credential	:
Telephone Number	:	423-914-1518

Provider Enumeration Date	:	01/15/2025
Last Update Date	:	01/15/2025

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