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General NPI Number Information
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NPI Number | 1851453500
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Entity Type | Organization
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Legal Business Name | MEDMARK TREATMENT CENTERS - STOCKTON, INC.
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Dates
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Enumeration Date | 12/15/2006
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Last Update Date | 07/29/2024
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Provider Practice Location Address
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Address Line | 1111 N EL DORADO STREET
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City | STOCKTON
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State | CA
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Zip | 95202-1305
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Country | US
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Telephone | 209-938-0228
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Fax | 209-938-0281
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Provider Business Mailing Address
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Address Line | 1720 LAKEPOINTE DR STE 117
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City | LEWISVILLE
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State | TX
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Zip | 75057-6425
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Country | US
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Telephone | 214-379-3300
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Fax | 214-853-9018
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Authorized Official
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Title or Position | VP, TREASURER
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Name | BRUCE JARVIE
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Credential |
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Telephone | 214-379-3300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2800X
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Taxonomy Name | Methadone Clinic
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License Number | 39-07
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License Number State | CA
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