Provider Demographics
NPI:1033624812
Name:OXYCLEAN AMBULATORY OPIATE DETOX CENTERS LLC
Entity Type:Organization
Organization Name:OXYCLEAN AMBULATORY OPIATE DETOX CENTERS LLC
Other - Org Name:NOT LTD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-718-7677
Mailing Address - Street 1:3195 DAYTON XENIA RD # 900-162
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-6390
Mailing Address - Country:US
Mailing Address - Phone:937-718-7677
Mailing Address - Fax:
Practice Address - Street 1:415 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:OH
Practice Address - Zip Code:45068-9553
Practice Address - Country:US
Practice Address - Phone:513-897-7162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050063207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35-0-50063OtherSTATE MEDICAL BOARD
1245220912OtherINDIVIDUAL NPI