=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447889621
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORRECTIONS - COMPREHENSIVE TREATMENT CENTERS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2020
-----------------------------------------------------
Last Update Date | 04/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | ONE BUMPS POND ROAD
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-422-3660
-----------------------------------------------------
Fax | 508-422-3666
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6185 PASEO DEL NORTE STE 150
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92011-1155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-259-2288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT, CTC DIVISION
-----------------------------------------------------
Name | KIM SANDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 855-259-2288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2800X
-----------------------------------------------------
Taxonomy Name | Methadone Clinic
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------