MEDICARE: MEDICATION ASSISTED TREATMENT CENTERS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1134628654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICATION ASSISTED TREATMENT CENTERS LLC

Provider Business Mailing Address
First Line	:	PO BOX 13566
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71315-3566
Country	:	US
Telephone Number	:	318-446-0231
Fax Number	:

Provider Business Practice Location Address
First Line	:	3030 JACKSON ST
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71301-4743
Country	:	US
Telephone Number	:	318-625-7111
Fax Number	:	318-625-7111

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. BENJAMIN K COOPER
Credential	:
Telephone Number	:	318-446-0231

Provider Enumeration Date	:	02/10/2018
Last Update Date	:	02/10/2018

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