1770781106 NPI number — MEDMARK TREATMENT CENTERS OF TEXAS, INC.

Table of content: (NPI 1770781106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770781106 NPI number — MEDMARK TREATMENT CENTERS OF TEXAS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDMARK TREATMENT CENTERS OF TEXAS, INC.
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:
6
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:
1770781106
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1720 LAKEPOINTE DR STE 117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75057-6425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-379-3300
Provider Business Mailing Address Fax Number:
214-853-9018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5201 MCCART AVE
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76115-3711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-207-8700
Provider Business Practice Location Address Fax Number:
817-207-8778
Provider Enumeration Date:
07/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JARVIE
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
Authorized Official Title or Position:
VP, TREASURER
Authorized Official Telephone Number:
214-379-3300

Provider Taxonomy Codes

  • Taxonomy code: 261QM2800X , with the licence number:  1000027 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X , with the licence number: 1000027 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1000027 . This is a "LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 285947202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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