Provider Demographics
NPI:1235803115
Name:SOUTHERN OHIO PREMIER RECOVERY, LLC
Entity Type:Organization
Organization Name:SOUTHERN OHIO PREMIER RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BIVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-981-6987
Mailing Address - Street 1:6587 STATE ROUTE 104
Mailing Address - Street 2:
Mailing Address - City:MC DERMOTT
Mailing Address - State:OH
Mailing Address - Zip Code:45652-8943
Mailing Address - Country:US
Mailing Address - Phone:740-981-6987
Mailing Address - Fax:
Practice Address - Street 1:6431 STATE ROUTE 104
Practice Address - Street 2:
Practice Address - City:MCDERMOTT
Practice Address - State:OH
Practice Address - Zip Code:45652-8943
Practice Address - Country:US
Practice Address - Phone:740-981-6987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-04
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities