Provider Demographics
NPI:1851453500
Name:MEDMARK TREATMENT CENTERS- STOCKTON, INC
Entity Type:Organization
Organization Name:MEDMARK TREATMENT CENTERS- STOCKTON, 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 1:1111 N EL DORADO STREET
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1305
Practice Address - Country:US
Practice Address - Phone:209-938-0228
Practice Address - Fax:209-938-0281
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDMARK SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-15
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39-07261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA48-ACMedicaid
CA48ACOtherMEDI-CAL