1932409729 NPI number — MAVERICK ADDICTION SERVICES, LLC

Table of content: (NPI 1932409729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932409729 NPI number — MAVERICK ADDICTION SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAVERICK ADDICTION SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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 Information

NPI Number:
1932409729
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 951
Provider Second Line Business Mailing Address:
35 S. STATE ST., SUITE 1
Provider Business Mailing Address City Name:
NORTH VERNON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47265-0951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-953-1181
Provider Business Mailing Address Fax Number:
812-953-1158

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 S STATE ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
NORTH VERNON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47265-1800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-953-1181
Provider Business Practice Location Address Fax Number:
812-953-1158
Provider Enumeration Date:
10/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
COX
Authorized Official First Name:
VICKIE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO & ADDICTION COUNSELOR
Authorized Official Telephone Number:
812-953-1181

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  86000039A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 104100000X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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