Provider Demographics
NPI:1710426036
Name:THREE WATERS RECOVERY CENTER, LLC
Entity Type:Organization
Organization Name:THREE WATERS RECOVERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:513-967-1460
Mailing Address - Street 1:6722 STATE ROUTE 132 STE A
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:OH
Mailing Address - Zip Code:45122-9346
Mailing Address - Country:US
Mailing Address - Phone:513-575-7879
Mailing Address - Fax:
Practice Address - Street 1:218 STERN RD
Practice Address - Street 2:
Practice Address - City:SEAMAN
Practice Address - State:OH
Practice Address - Zip Code:45679-9607
Practice Address - Country:US
Practice Address - Phone:513-967-1460
Practice Address - Fax:513-456-2855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-20
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0244638Medicaid