Basic Information
| Provider Information | |||||||||
| NPI: | 1043584402 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METRO TREATMENT OF MISSOURI, LP | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CAPE GIRARDEAU METRO TREATMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 MAITLAND CENTER PARKWAY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327514174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073517080 | ||||||||
| FaxNumber: | 4073516930 | ||||||||
| Practice Location | |||||||||
| Address1: | 760 S. KINGS HIGHWAY | ||||||||
| Address2: | SUITE F | ||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637037676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733354333 | ||||||||
| FaxNumber: | 5733354345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2012 | ||||||||
| LastUpdateDate: | 08/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4075815157 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | METRO TREATMENT OF MISSOURL, LP | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 3336C0002X | 1339 | MO | N | Suppliers | Pharmacy | Clinic Pharmacy | 251S00000X | MO | Y | Agencies | Community/Behavioral Health |
No ID Information.