Provider Demographics
NPI:1366838336
Name:NORTHWEST INDIANA TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:NORTHWEST INDIANA TREATMENT CENTER, LLC
Other - Org Name:MEDMARK TREATMENT CENTERS MERRILLVILLE
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 DRIVE
Mailing Address - Street 2:SUITE 117
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-6425
Mailing Address - Country:US
Mailing Address - Phone:214-379-3000
Mailing Address - Fax:214-853-9018
Practice Address - Street 1:8500 BROADWAY
Practice Address - Street 2:SUITE H
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7006
Practice Address - Country:US
Practice Address - Phone:219-769-7710
Practice Address - Fax:219-769-7758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1177-2-OTFOtherSUBSTANCE ABUSE