Provider Demographics
NPI:1528711801
Name:NEW LIFE RECOVERY CLINIC 2
Entity type:Organization
Organization Name:NEW LIFE RECOVERY CLINIC 2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AKARI
Authorized Official - Middle Name:
Authorized Official - Last Name:TICHAVAKUNDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-770-3130
Mailing Address - Street 1:1414 S GREEN RD STE 107
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-3936
Mailing Address - Country:US
Mailing Address - Phone:440-627-2600
Mailing Address - Fax:440-627-2600
Practice Address - Street 1:25201 CHAGRIN BLVD STE 390
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5637
Practice Address - Country:US
Practice Address - Phone:216-770-3130
Practice Address - Fax:216-770-3100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1366431850Medicaid