Healthcare Provider Details

I. General information

NPI: 1952854408
Provider Name (Legal Business Name): MEDMARK TREATMENT CENTERS OF PENNSYLVANIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1984 ROUTE 22
BLAIRSVILLE PA
15717-1264
US

IV. Provider business mailing address

1720 LAKEPOINTE DR STE 117
LEWISVILLE TX
75057-6425
US

V. Phone/Fax

Practice location:
  • Phone: 724-459-4884
  • Fax: 724-459-4886
Mailing address:
  • Phone: 214-379-3300
  • Fax: 214-853-9018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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