Provider Demographics
NPI:1396387478
Name:CORYDON RECOVERY LLC
Entity Type:Organization
Organization Name:CORYDON RECOVERY LLC
Other - Org Name:HICKORY TREATMENT CENTER AT CORYDON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BROMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-784-4402
Mailing Address - Street 1:PO BOX 191310
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-7310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-1751
Practice Address - Country:US
Practice Address - Phone:812-738-2190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-10
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility