Provider Demographics
NPI:1053944033
Name:PORT45 RECOVERY LLC
Entity type:Organization
Organization Name:PORT45 RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCBRIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-591-4710
Mailing Address - Street 1:921 EASTWIND DR STE 101
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-5302
Mailing Address - Country:US
Mailing Address - Phone:614-591-4710
Mailing Address - Fax:
Practice Address - Street 1:1907 11TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4531
Practice Address - Country:US
Practice Address - Phone:740-529-7356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty