Provider Demographics
NPI:1558874461
Name:PINNACLE TREATMENT CENTERS VA-I, LLC
Entity Type:Organization
Organization Name:PINNACLE TREATMENT CENTERS VA-I, LLC
Other - Org Name:FCCR SOUTHLAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC DIR CONTRACT MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:TANIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-533-8762
Mailing Address - Street 1:1317 ROUTE 73
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2202
Mailing Address - Country:US
Mailing Address - Phone:856-533-8762
Mailing Address - Fax:
Practice Address - Street 1:905 SOUTHLAKE BLVD
Practice Address - Street 2:SUITES A & C
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-3955
Practice Address - Country:US
Practice Address - Phone:804-354-1996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No251S00000XAgenciesCommunity/Behavioral Health
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care