Organization
OXYCLEAN AMBULATORY OPIATE DETOX CENTERS LLC
Active
Other names
NOT ltd
Organization subpart
No
Provider details
NPI number
Authorized official
DR. CHARLES EDWARD RUSSELL MD (PRESIDENT)
(937) 718-7677
Entity
Organization
Contact information
Practice address
415 S MAIN ST, WAYNESVILLE, OH 45068-9553
(513) 897-7162
Mailing address
3195 DAYTON XENIA RD # 900-162, BEAVERCREEK, OH 45434-6390
(937) 718-7677
Taxonomy
Speciality
Code
Description
License number
State
207QA0401X
Addiction Medicine (Family Medicine) Physician
Primary
35050063
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1245220912
INDIVIDUAL NPI
—
01
—
35-0-50063
STATE MEDICAL BOARD
OH
Enumeration date
12/03/2017
Last updated
03/17/2018
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