Healthcare Provider Details

I. General information

NPI: 1912233826
Provider Name (Legal Business Name): MERRIMACK RIVER MEDICAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2009
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 CONGRESS ST
PORTLAND ME
04102-1908
US

IV. Provider business mailing address

1720 LAKEPOINTE DR
LEWISVILLE TX
75057-6458
US

V. Phone/Fax

Practice location:
  • Phone: 207-221-2292
  • Fax: 207-221-2297
Mailing address:
  • Phone: 214-379-3300
  • Fax: 214-853-9018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BRUCE JARVIE
Title or Position: VP, TREASURER
Credential:
Phone: 214-379-3300