Provider Demographics
NPI:1225389638
Name:BLOOMINGTON-NORMAL TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:BLOOMINGTON-NORMAL TREATMENT CENTER, LLC
Other - Org Name:MEDMARK TREATMENT CENTERS NORMAL
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 1:303 LANDMARK DR
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2153
Mailing Address - Country:US
Mailing Address - Phone:309-808-2388
Mailing Address - Fax:
Practice Address - Street 1:303 LANDMARK DR STE 2B
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6164
Practice Address - Country:US
Practice Address - Phone:309-808-2388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-25
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251S00000X
261QM2800X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder