Provider Demographics
NPI:1326423534
Name:TEREO NARCOTIC TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:TEREO NARCOTIC TREATMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:BA,CSAC,ICS
Authorized Official - Phone:262-260-8370
Mailing Address - Street 1:2405 NORTHWESTERN AVE
Mailing Address - Street 2:SUITE LOWER LEVEL
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404-2534
Mailing Address - Country:US
Mailing Address - Phone:262-260-8370
Mailing Address - Fax:262-260-8538
Practice Address - Street 1:2405 NORTHWESTERN AVE
Practice Address - Street 2:SUITE LOWER LEVEL
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-2534
Practice Address - Country:US
Practice Address - Phone:262-260-8370
Practice Address - Fax:262-260-8538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-29
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone