Provider Demographics
NPI:1619148897
Name:MILLENNIUM TREATMENT SERVICES LLC
Entity Type:Organization
Organization Name:MILLENNIUM TREATMENT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:COSIMO
Authorized Official - Last Name:CLEMENTE
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:586-758-6670
Mailing Address - Street 1:1400 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2651
Mailing Address - Country:US
Mailing Address - Phone:248-547-2223
Mailing Address - Fax:248-547-2226
Practice Address - Street 1:23700 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-1669
Practice Address - Country:US
Practice Address - Phone:586-758-6670
Practice Address - Fax:586-758-0243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI500371261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500371Medicaid
MIOP12910Medicare PIN