Provider Demographics
NPI:1568926376
Name:SQUARE ONE HEALTH LLC
Entity Type:Organization
Organization Name:SQUARE ONE HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:DUFOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-231-1789
Mailing Address - Street 1:620 W 44TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-6812
Mailing Address - Country:US
Mailing Address - Phone:602-736-6973
Mailing Address - Fax:
Practice Address - Street 1:620 W 44TH ST
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-6812
Practice Address - Country:US
Practice Address - Phone:602-736-6973
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-25
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder