Basic Information
| Provider Information | |||||||||
| NPI: | 1639606759 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYLAND TREATMENT CENTERS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | THE SHOEMAKER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9701 KEYSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | EMMITSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217278619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014472361 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6655 SYKESVILLE RD | ||||||||
| Address2: | |||||||||
| City: | SYKESVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217847966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108761989 | ||||||||
| FaxNumber: | 4108761690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2017 | ||||||||
| LastUpdateDate: | 05/19/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOLEK | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACTS COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2404013062 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARYLAND TREATMENT CENTERS INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | MD | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.