Healthcare Provider Details

I. General information

NPI: 1134628654
Provider Name (Legal Business Name): MEDICATION ASSISTED TREATMENT CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2018
Last Update Date: 02/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 JACKSON ST
ALEXANDRIA LA
71301-4743
US

IV. Provider business mailing address

PO BOX 13566
ALEXANDRIA LA
71315-3566
US

V. Phone/Fax

Practice location:
  • Phone: 318-625-7111
  • Fax: 318-625-7111
Mailing address:
  • Phone: 318-446-0231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. BENJAMIN K COOPER
Title or Position: MANAGER
Credential:
Phone: 318-446-0231