Healthcare Provider Details

I. General information

NPI: 1679012215
Provider Name (Legal Business Name): OPIATE TREATMENT CENTERS OF AMERICA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 09/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9846 LORENE LN
SAN ANTONIO TX
78216-4438
US

IV. Provider business mailing address

8647 WURZBACH RD BUILDING J100
SAN ANTONIO TX
78240-1225
US

V. Phone/Fax

Practice location:
  • Phone: 210-340-0049
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number72477
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number70240
License Number StateTX

VIII. Authorized Official

Name: JASON HAHN
Title or Position: MANAGING-MEMBER
Credential:
Phone: 210-529-0208