MEDICARE: MEDMARK TREATMENT CENTERS OF TEXAS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2800X	Methadone Clinic	0000058	TX
2	261QM2800X	Methadone Clinic	1000028	TX
3	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	1000028	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1000028	OTHER	TX	ST LICENSE

General Provider Information

NPI Number	:	1083931562
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDMARK TREATMENT CENTERS OF TEXAS, INC.

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

Provider Business Practice Location Address
First Line	:	2210 WASHINGTON AVE
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76701-1019
Country	:	US
Telephone Number	:	254-755-6411
Fax Number	:	254-755-6422

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

Provider Enumeration Date	:	04/23/2010
Last Update Date	:	07/29/2024

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