Healthcare Provider Details

I. General information

NPI: 1730623737
Provider Name (Legal Business Name): MEDITOX CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2016
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 POST RD W
WESTPORT CT
06880-4602
US

IV. Provider business mailing address

179 POST RD W
WESTPORT CT
06880-4602
US

V. Phone/Fax

Practice location:
  • Phone: 203-450-4882
  • Fax: 866-505-8927
Mailing address:
  • Phone: 203-450-4882
  • Fax: 866-505-8927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MOHAMED ELSAMRA
Title or Position: OWNER AND MANAGER
Credential: MD
Phone: 203-450-4882