Provider Demographics
NPI:1346372380
Name:BLACK ALCOHOL DRUG SERVICE INFORMATION CENTER
Entity Type:Organization
Organization Name:BLACK ALCOHOL DRUG SERVICE INFORMATION CENTER
Other - Org Name:B.A.S.I.C.
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:OVAL
Authorized Official - Middle Name:LAVAL
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:314-621-9009
Mailing Address - Street 1:2600 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1420
Mailing Address - Country:US
Mailing Address - Phone:314-621-9009
Mailing Address - Fax:314-621-1071
Practice Address - Street 1:2600 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1420
Practice Address - Country:US
Practice Address - Phone:314-621-9009
Practice Address - Fax:314-621-1071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility