Provider Demographics
NPI:1760576565
Name:INTERVAL BROTHERHOOD HOMES, INC.
Entity Type:Organization
Organization Name:INTERVAL BROTHERHOOD HOMES, INC.
Other - Org Name:IBH ADDICTION RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:SLOANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-237-6878
Mailing Address - Street 1:3445 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44319-3028
Mailing Address - Country:US
Mailing Address - Phone:330-644-4095
Mailing Address - Fax:330-645-2031
Practice Address - Street 1:3445 S MAIN ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44319-3028
Practice Address - Country:US
Practice Address - Phone:330-644-4095
Practice Address - Fax:330-645-2031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X, 261QR0405X, 320800000X
OH1505324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1505Medicare UPIN