Provider Demographics
NPI:1932166220
Name:FIVE COUNTY ALCOHOL/DRUG PROGRAM SERENITY HAVEN
Entity Type:Organization
Organization Name:FIVE COUNTY ALCOHOL/DRUG PROGRAM SERENITY HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BOND
Authorized Official - Suffix:
Authorized Official - Credentials:LICDC
Authorized Official - Phone:419-782-9920
Mailing Address - Street 1:830 S CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-2758
Mailing Address - Country:US
Mailing Address - Phone:419-782-9920
Mailing Address - Fax:419-784-2523
Practice Address - Street 1:25212 US ROUTE 20
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:OH
Practice Address - Zip Code:43521-9511
Practice Address - Country:US
Practice Address - Phone:419-237-3103
Practice Address - Fax:419-237-4044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7111251B00000X, 261Q00000X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251B00000XAgenciesCase Management
Not Answered261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Not Answered261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH07111OtherMACSIS UPI