Provider Demographics
NPI:1568676575
Name:MEDMARK TREATMENT CENTERS - FRESNO WEST, INC
Entity Type:Organization
Organization Name:MEDMARK TREATMENT CENTERS - FRESNO WEST, INC
Other - Org Name:
Other - Org Type:
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 DR STE 117
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-6425
Mailing Address - Country:US
Mailing Address - Phone:214-379-3300
Mailing Address - Fax:214-853-9018
Practice Address - Street 1:1310 M STREET
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1808
Practice Address - Country:US
Practice Address - Phone:559-264-2700
Practice Address - Fax:559-264-2767
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDMARK SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-09
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPENDING173000000X
CA10-06261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10-97Medicaid