Provider Demographics
NPI:1588012488
Name:EAST COAST REHABILITATION CENTERS
Entity Type:Organization
Organization Name:EAST COAST REHABILITATION CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:IV
Authorized Official - Credentials:LCADC
Authorized Official - Phone:606-369-4617
Mailing Address - Street 1:512 EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:ST MATTHEWS
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4205
Mailing Address - Country:US
Mailing Address - Phone:502-415-9289
Mailing Address - Fax:
Practice Address - Street 1:512 EXECUTIVE PARK
Practice Address - Street 2:
Practice Address - City:ST MATTHEWS
Practice Address - State:KY
Practice Address - Zip Code:40207-4205
Practice Address - Country:US
Practice Address - Phone:502-415-9289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYADCLAD00222794324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility