Healthcare Provider Details

I. General information

NPI: 1851506091
Provider Name (Legal Business Name): PROVIDENCE METRO TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 NARRAGANSETT AVE
PROVIDENCE RI
02907-3367
US

IV. Provider business mailing address

14050 TOWN LOOP BLVD SUITE 204
ORLANDO FL
32837-6190
US

V. Phone/Fax

Practice location:
  • Phone: 401-941-4488
  • Fax: 401-941-9797
Mailing address:
  • Phone: 407-351-7080
  • Fax: 407-351-6930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number614, 614.1
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberCMC00033
License Number StateRI

VIII. Authorized Official

Name: MR. LARRY KACZMAREK
Title or Position: CONTROLLER
Credential:
Phone: 407-351-7080