Provider Demographics
NPI:1023737012
Name:GEMINI TREATMENT CENTER, LLC
Entity type:Organization
Organization Name:GEMINI TREATMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:443-202-1685
Mailing Address - Street 1:705 E PATAPSCO AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21225-1934
Mailing Address - Country:US
Mailing Address - Phone:410-891-6677
Mailing Address - Fax:
Practice Address - Street 1:705 E PATAPSCO AVE STE A
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-1934
Practice Address - Country:US
Practice Address - Phone:410-891-6677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-24
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDNAMedicaid