1760922207 NPI number — AEGIS TREATMENT CENTERS, LLC

Table of content: (NPI 1760922207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760922207 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:
1760922207
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:
1137 HARTNELL AVENUE, SUITE D & E
Provider Second Line Business Practice Location Address:
1129, 1133, 1135, 1141, 1145 & 1147 HARTNELL AVENUE
Provider Business Practice Location Address City Name:
REDDING
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96002-2113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-345-3491
Provider Business Practice Location Address Fax Number:
530-345-0261
Provider Enumeration Date:
03/02/2017

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 , with the licence number:  04-02MU1 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04-02MU1 . This is a "CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES - NTP LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CA10,297 . This is a "CSAT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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