Provider Demographics
NPI:1033608195
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 810
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:855-686-6641
Practice Address - Street 1:1757 INDIAN WOOD CIR
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:866-806-0308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWEST DETOX CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-04
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH01-7617324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0281740Medicaid