Basic Information
| Provider Information | |||||||||
| NPI: | 1467998344 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MISSISSIPPI COMPREHENSIVE TREATMENT CENTERS, LLC | ||||||||
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| OtherOrganizationName: | GULF COAST COMPREHENSIVE TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6185 PASEO DEL NORTE STE 150 | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552592288 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14070 DEDEAUX RD | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395034502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8775335686 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2017 | ||||||||
| LastUpdateDate: | 01/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | PELOQUIN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT, CTC DIVISION | ||||||||
| AuthorizedOfficialTelephone: | 8552592288 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.