1275509143 NPI number — ALCOHOL AND DRUG FREEDOM CENTER OF KNOX COUNTY

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275509143 NPI number — ALCOHOL AND DRUG FREEDOM CENTER OF KNOX COUNTY

Employer Identification Number (EIN):

Provider Organization Name:

ALCOHOL AND DRUG FREEDOM CENTER OF KNOX COUNTY

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

FREEDOM CENTER

Provider Other Organization Name Type Code:

5

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1275509143

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

09/28/2016

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

106 E GAMBIER ST

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

MOUNT VERNON

Provider Business Mailing Address State Name:

OH

Provider Business Mailing Address Postal Code:

43050-3510

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

740-397-2660

Provider Business Mailing Address Fax Number:

740-392-3613

Provider First Line Business Practice Location Address:

106 E GAMBIER ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

MOUNT VERNON

Provider Business Practice Location Address State Name:

OH

Provider Business Practice Location Address Postal Code:

43050-3510

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

740-397-2660

Provider Business Practice Location Address Fax Number:

740-392-3613

Provider Enumeration Date:

02/28/2006

Authorized Official Last Name:

WILLIAMS

Authorized Official First Name:

JEFFREY

Authorized Official Middle Name:

Authorized Official Title or Position:

EXECUTIVE DIRECTOR

Authorized Official Telephone Number:

740-397-2660

• Taxonomy code: 101YA0400X , with the licence number:  1311 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 251S00000X , with the licence number: 01-7560 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 35842 . This is a "MBC (MERIT/BIODYNE)" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: OH750732-00 . This is a "NFR ID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 1311 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 729264 . This is a "BWC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: LICKBO131199 . This is a "PSEUDO UCI" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 45660 . This is a "ODADAS AGENCY NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 62-15262 . This is a "PHP/UBS NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 3908853 . This is a "FDA ID#" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 62-15262 . This is a "UHC OR UBH NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".