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General NPI Number Information
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NPI Number | 1104144088
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Entity Type | Organization
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Legal Business Name | METHADONE CLINIC OF EAST TEXAS LLC
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Dates
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Enumeration Date | 05/17/2010
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Last Update Date | 09/03/2024
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Provider Practice Location Address
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Address Line | 1510 S VINE AVE
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City | TYLER
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State | TX
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Zip | 75701-2826
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Country | US
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Telephone | 800-805-6989
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 749057
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City | ATLANTA
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State | GA
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Zip | 30374-9057
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Country | US
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Telephone | 800-805-6989
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Fax | 864-558-8511
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | RUPERT MCCORMAC
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Credential | MD
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Telephone | 800-805-6898
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State | TX
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Taxonomy #4
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 261QM2800X
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Taxonomy Name | Methadone Clinic
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License Number | 000039
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License Number State | TX
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