Healthcare Provider Details

I. General information

NPI: 1295395408
Provider Name (Legal Business Name): COLEMAN ADDICTION MEDICINE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23-00 STATE RT 208 STE 1-1
FAIR LAWN NJ
07410-1558
US

IV. Provider business mailing address

1720 LAKEPOINTE DR STE 117
LEWISVILLE TX
75057-6425
US

V. Phone/Fax

Practice location:
  • Phone: 617-996-8365
  • Fax:
Mailing address:
  • Phone: 214-379-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: GENCO D'ANDRIA
Title or Position: CFO
Credential:
Phone: 214-379-3300