Provider Demographics
NPI:1669833588
Name:MID-ATLANTIC BUREAU OF SOBRIETY AND RECOVERY
Entity Type:Organization
Organization Name:MID-ATLANTIC BUREAU OF SOBRIETY AND RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:GAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-627-1000
Mailing Address - Street 1:1336 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2081
Mailing Address - Country:US
Mailing Address - Phone:646-320-4358
Mailing Address - Fax:
Practice Address - Street 1:1336 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2081
Practice Address - Country:US
Practice Address - Phone:646-320-4358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-20
Last Update Date:2016-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility