Provider Demographics
NPI:1073944567
Name:PEORIA TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:PEORIA TREATMENT CENTER, LLC
Other - Org Name:MEDMARK TREATMENT CENTERS EAST PEORIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-379-3300
Mailing Address - Street 1:1720 LAKEPOINTE DR STE 117
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-6425
Mailing Address - Country:US
Mailing Address - Phone:214-379-3300
Mailing Address - Fax:
Practice Address - Street 1:731 SABRINA DR UNIT C
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-3582
Practice Address - Country:US
Practice Address - Phone:877-592-5901
Practice Address - Fax:402-592-5901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder