Provider Demographics
NPI:1093357188
Name:TERRE HAUTE RECOVERY LLC
Entity Type:Organization
Organization Name:TERRE HAUTE RECOVERY LLC
Other - Org Name:HICKORY TREATMENT CENTER AT TERRE HAUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BROMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-784-4402
Mailing Address - Street 1:PO BOX 191310
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-7310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 S 6TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-4712
Practice Address - Country:US
Practice Address - Phone:812-232-7102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-10
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility