Provider Demographics
NPI:1326790262
Name:INDIANA CENTER FOR RECOVERY SOUTH BEND, LLC
Entity Type:Organization
Organization Name:INDIANA CENTER FOR RECOVERY SOUTH BEND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIRILL
Authorized Official - Middle Name:
Authorized Official - Last Name:VESSELOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-305-0461
Mailing Address - Street 1:2925 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-3000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1917
Practice Address - Country:US
Practice Address - Phone:561-305-0461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-21
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility