=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184880734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSIGHT TREATMENT PROGRAM, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2008
-----------------------------------------------------
Last Update Date | 08/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 COURT ST
-----------------------------------------------------
City | GROVE HILL
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36451-3263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-275-3036
-----------------------------------------------------
Fax | 251-275-3721
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 E I65 SERVICE RD S SUITE A-7
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36606-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-473-6093
-----------------------------------------------------
Fax | 251-473-6469
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. THOMAS EUGENE LEE JR.
-----------------------------------------------------
Credential | BS
-----------------------------------------------------
Telephone | 251-473-6093
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------