Provider Demographics
NPI:1003337734
Name:MIDWEST DETOX CENTER LLC
Entity Type:Organization
Organization Name:MIDWEST DETOX CENTER LLC
Other - Org Name:OHIO DETOX CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-243-7219
Mailing Address - Street 1:10461 MILL RUN CIR STE 801
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1757 INDIAN WOOD CIR STE A
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-4009
Practice Address - Country:US
Practice Address - Phone:866-203-0308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-03
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0281740Medicaid