Provider Demographics
NPI:1720714561
Name:LEGEND TREATMENT CENTER OF CLEVELAND, LLC
Entity Type:Organization
Organization Name:LEGEND TREATMENT CENTER OF CLEVELAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE/PROJECT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:EVA
Authorized Official - Middle Name:I
Authorized Official - Last Name:DUDEK
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MHA, CAP
Authorized Official - Phone:561-301-9423
Mailing Address - Street 1:95 MAIN AVE STE 121
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07014-1757
Mailing Address - Country:US
Mailing Address - Phone:844-534-3638
Mailing Address - Fax:
Practice Address - Street 1:14445 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44125-1957
Practice Address - Country:US
Practice Address - Phone:844-534-3638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility