Provider Demographics
NPI:1851506091
Name:PROVIDENCE METRO TREATMENT CENTER
Entity Type:Organization
Organization Name:PROVIDENCE METRO TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KACZMAREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-351-7080
Mailing Address - Street 1:14050 TOWN LOOP BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-6190
Mailing Address - Country:US
Mailing Address - Phone:407-351-7080
Mailing Address - Fax:407-351-6930
Practice Address - Street 1:160 NARRAGANSETT AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-3367
Practice Address - Country:US
Practice Address - Phone:401-941-4488
Practice Address - Fax:401-941-9797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI614, 614.1251S00000X
RICMC000333336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No3336C0002XSuppliersPharmacyClinic Pharmacy