Provider Demographics
NPI:1083148076
Name:ETOWN ADDICTION SOLUTIONS, LLC
Entity Type:Organization
Organization Name:ETOWN ADDICTION SOLUTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC/TREAS.
Authorized Official - Prefix:
Authorized Official - First Name:BRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-367-9446
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-0897
Mailing Address - Country:US
Mailing Address - Phone:208-367-9446
Mailing Address - Fax:
Practice Address - Street 1:2645 LEITCHFIELD RD STE 104
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-8306
Practice Address - Country:US
Practice Address - Phone:270-234-8180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone