Provider Demographics
NPI:1912648528
Name:DIVINE INTERVENTION RECOVERY CENTER, LLC
Entity Type:Organization
Organization Name:DIVINE INTERVENTION RECOVERY CENTER, LLC
Other - Org Name:DIVINE INTERVENTION RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FAYETTA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BARRON
Authorized Official - Suffix:
Authorized Official - Credentials:LISWS
Authorized Official - Phone:937-241-9230
Mailing Address - Street 1:7373 DAYTON SPRINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ENON
Mailing Address - State:OH
Mailing Address - Zip Code:45323-1462
Mailing Address - Country:US
Mailing Address - Phone:937-862-0008
Mailing Address - Fax:
Practice Address - Street 1:7373 DAYTON SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:ENON
Practice Address - State:OH
Practice Address - Zip Code:45323-1462
Practice Address - Country:US
Practice Address - Phone:937-862-0008
Practice Address - Fax:937-340-7004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-06
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty