=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063308864
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILESTONE TREATMENT CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2025
-----------------------------------------------------
Last Update Date | 06/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 LASKIN RD
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23451-5209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-406-2829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1101 LASKIN RD
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23451-5209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-406-2829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-FOUNDER
-----------------------------------------------------
Name | MR. JASON GOOBERMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 856-449-6159
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------