Healthcare Provider Details

I. General information

NPI: 1134565740
Provider Name (Legal Business Name): AEGIS TREATMENT CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 W. CENTER STREET, SUITES 12A, 12B & 14
MANTECA CA
95337
US

IV. Provider business mailing address

1317 ROUTE 73 STE 200
MOUNT LAUREL NJ
08054-2202
US

V. Phone/Fax

Practice location:
  • Phone: 209-239-9600
  • Fax:
Mailing address:
  • Phone: 856-439-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number39-14
License Number StateCA

VIII. Authorized Official

Name: DENISE WINANT
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 732-570-0268