Provider Demographics
NPI: | 1851664262 |
---|---|
Name: | MEDMARK TREATMENT CENTER FRESNO |
Entity Type: | Organization |
Organization Name: | MEDMARK TREATMENT CENTER FRESNO |
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 ST |
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: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-02-15 |
Last Update Date: | 2024-02-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | VN258988 | 171M00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 171M00000X | Other Service Providers | Case Manager/Care Coordinator | Group - Single Specialty |