Provider Demographics
NPI:1750648424
Name:KEYSTONE RICHLAND CENTER, LLC
Entity Type:Organization
Organization Name:KEYSTONE RICHLAND CENTER, LLC
Other - Org Name:FOUNDATIONS FOR LIVING AOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:REBANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-589-5511
Mailing Address - Street 1:1451 LUCAS RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-8682
Mailing Address - Country:US
Mailing Address - Phone:419-589-5511
Mailing Address - Fax:615-250-1000
Practice Address - Street 1:1451 LUCAS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-8682
Practice Address - Country:US
Practice Address - Phone:419-589-5511
Practice Address - Fax:615-250-1000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11-20793245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children