Healthcare Provider Details

I. General information

NPI: 1083148076
Provider Name (Legal Business Name): ETOWN ADDICTION SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2645 LEITCHFIELD RD STE 104
ELIZABETHTOWN KY
42701-8306
US

IV. Provider business mailing address

PO BOX 897
BOISE ID
83701-0897
US

V. Phone/Fax

Practice location:
  • Phone: 270-234-8180
  • Fax:
Mailing address:
  • Phone: 208-367-9446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State

VIII. Authorized Official

Name: JAY HIGHAM
Title or Position: CEO
Credential:
Phone: 214-365-6112