1104982495 NPI number — AEGIS TREATMENT CENTERS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104982495 NPI number — AEGIS TREATMENT CENTERS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AEGIS TREATMENT CENTERS, 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:
1104982495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1317 ROUTE 73 STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT LAUREL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08054-2202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-439-6111
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1343 W MAIN ST STE A&B
Provider Second Line Business Practice Location Address:
1349 W. MAIN STREET
Provider Business Practice Location Address City Name:
MERCED
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95340-4438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-725-1060
Provider Business Practice Location Address Fax Number:
209-725-1064
Provider Enumeration Date:
12/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WINANT
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SUPERVISOR
Authorized Official Telephone Number:
732-570-0268

Provider Taxonomy Codes

  • Taxonomy code: 261QM2800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: HDC70112F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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