MEDICARE: PINNACLE TREATMENT CENTERS OH-III, 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	261QM2800X	Methadone Clinic

General Provider Information

NPI Number	:	1679064703
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINNACLE TREATMENT CENTERS OH-III, LLC

Provider Business Mailing Address
First Line	:	1317 ROUTE 73
Second Line	:
City	:	MOUNT LAUREL
State	:	NJ
Zip	:	08054-2202
Country	:	US
Telephone Number	:	856-439-6111
Fax Number	:

Provider Business Practice Location Address
First Line	:	87 CONSERVATORY DR
Second Line	:
City	:	BARBERTON
State	:	OH
Zip	:	44203-4291
Country	:	US
Telephone Number	:	234-334-0306
Fax Number	:	234-334-4832

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR OF CONTRACT MGMT
Name	:	ROBYN TANIS
Credential	:
Telephone Number	:	856-533-8762

Provider Enumeration Date	:	05/24/2018
Last Update Date	:	12/23/2019

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