Provider Demographics
NPI:1336848076
Name:INDIANA CENTER FOR RECOVERY OUTPATIENT SERVICES LLC
Entity Type:Organization
Organization Name:INDIANA CENTER FOR RECOVERY OUTPATIENT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIRILL
Authorized Official - Middle Name:
Authorized Official - Last Name:VESSELOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-305-0461
Mailing Address - Street 1:2925 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-3000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 N SHORE DR STE 102
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3144
Practice Address - Country:US
Practice Address - Phone:561-635-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDIANA CENTER FOR RECOVERY OUTPATIENT SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-02
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility