Provider Demographics
NPI:1013418599
Name:EAST INDIANA RECOVERY, LLC
Entity Type:Organization
Organization Name:EAST INDIANA RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLODZIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-825-6220
Mailing Address - Street 1:117 S DIXIE DR STE 3
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-2142
Mailing Address - Country:US
Mailing Address - Phone:937-416-5442
Mailing Address - Fax:
Practice Address - Street 1:1528 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1844
Practice Address - Country:US
Practice Address - Phone:937-416-5442
Practice Address - Fax:765-935-0073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty