Provider Demographics
NPI:1548407109
Name:E.D. TREATMENT CENTER LLC
Entity Type:Organization
Organization Name:E.D. TREATMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:574-232-3000
Mailing Address - Street 1:2610 E JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-2724
Mailing Address - Country:US
Mailing Address - Phone:574-232-3000
Mailing Address - Fax:574-236-4409
Practice Address - Street 1:2610 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-2724
Practice Address - Country:US
Practice Address - Phone:574-232-3000
Practice Address - Fax:574-236-4409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-19
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1029868207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty