Provider Demographics
NPI:1013011238
Name:UNIVERSAL TREATMENT AND RECOVERY CENTER LLC
Entity Type:Organization
Organization Name:UNIVERSAL TREATMENT AND RECOVERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:VAN SKYHOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:440-324-4488
Mailing Address - Street 1:42553 NORTH RIDGE ROAD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035
Mailing Address - Country:US
Mailing Address - Phone:440-324-4488
Mailing Address - Fax:440-324-2465
Practice Address - Street 1:42553 NORTH RIDGE ROAD
Practice Address - Street 2:SUITE 8
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035
Practice Address - Country:US
Practice Address - Phone:440-324-4488
Practice Address - Fax:440-324-2465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1467111N00000X
OH3541111N00000X
111NR0400X
OH34004082207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2948369Medicaid
OH2948369Medicaid