Provider Demographics
NPI:1255852992
Name:MIDWEST RECOVERY CENTER LLC
Entity Type:Organization
Organization Name:MIDWEST RECOVERY CENTER LLC
Other - Org Name:
Other - Org Type:
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:866-203-0308
Mailing Address - Fax:
Practice Address - Street 1:4747 MONROE ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4307
Practice Address - Country:US
Practice Address - Phone:833-654-1029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-03
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0309004Medicaid
OH0326341Medicaid