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General NPI Number Information
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NPI Number | 1851506091
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Entity Type | Organization
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Legal Business Name | PROVIDENCE METRO TREATMENT CENTER
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Dates
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Enumeration Date | 05/11/2007
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Last Update Date | 12/03/2007
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Provider Practice Location Address
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Address Line | 160 NARRAGANSETT AVE
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City | PROVIDENCE
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State | RI
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Zip | 02907-3367
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Country | US
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Telephone | 401-941-4488
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Fax | 401-941-9797
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Provider Business Mailing Address
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Address Line | 14050 TOWN LOOP BLVD SUITE 204
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City | ORLANDO
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State | FL
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Zip | 32837-6190
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Country | US
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Telephone | 407-351-7080
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Fax | 407-351-6930
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Authorized Official
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Title or Position | CONTROLLER
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Name | MR. LARRY KACZMAREK
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Credential |
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Telephone | 407-351-7080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number | CMC00033
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License Number State | RI
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 614, 614.1
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License Number State | RI
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