Provider Demographics
NPI:1093772386
Name:FIVE COUNTY ALCOHOL/DRUP PROGRAM IN
Entity Type:Organization
Organization Name:FIVE COUNTY ALCOHOL/DRUP PROGRAM IN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BOND
Authorized Official - Suffix:IV
Authorized Official - Credentials:LICDC
Authorized Official - Phone:419-782-9920
Mailing Address - Street 1:830 S CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-2758
Mailing Address - Country:US
Mailing Address - Phone:419-782-9920
Mailing Address - Fax:419-784-2523
Practice Address - Street 1:109 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ALVORDTON
Practice Address - State:OH
Practice Address - Zip Code:43501-9763
Practice Address - Country:US
Practice Address - Phone:419-924-2029
Practice Address - Fax:419-924-2061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0559261QM0801X, 261QM0850X, 332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Not Answered261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Not Answered332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH10998OtherMACSIS UPI