Healthcare Provider Details

I. General information

NPI: 1104144088
Provider Name (Legal Business Name): METHADONE CLINIC OF EAST TEXAS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 S VINE AVE
TYLER TX
75701-2826
US

IV. Provider business mailing address

PO BOX 749057
ATLANTA GA
30374-9057
US

V. Phone/Fax

Practice location:
  • Phone: 800-805-6989
  • Fax:
Mailing address:
  • Phone: 800-805-6989
  • Fax: 864-558-8511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number000039
License Number StateTX

VIII. Authorized Official

Name: RUPERT MCCORMAC
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 800-805-6898