Healthcare Provider Details

I. General information

NPI: 1962680751
Provider Name (Legal Business Name): NORTHEAST TREATMENT CENTERS. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 N 5TH ST SUITE D-E
PHILADELPHIA PA
19123-4005
US

IV. Provider business mailing address

499 N 5TH ST SUITE A
PHILADELPHIA PA
19123-4005
US

V. Phone/Fax

Practice location:
  • Phone: 215-451-7100
  • Fax: 215-925-6897
Mailing address:
  • Phone: 215-451-7000
  • Fax: 215-925-6897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number910194
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number910194
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number910194
License Number StatePA

VIII. Authorized Official

Name: MR. KEVIN NOEL
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 215-451-7000