Basic Information
| Provider Information | |||||||||
| NPI: | 1669534491 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDMARK TREATMENT CENTERS- FAIRFIELD, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 LAKEPOINTE DR STE 117 | ||||||||
| Address2: | |||||||||
| City: | LEWISVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750576425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143793300 | ||||||||
| FaxNumber: | 2148539018 | ||||||||
| Practice Location | |||||||||
| Address1: | 1143 MISSOURI STREET | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945336007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074359911 | ||||||||
| FaxNumber: | 7074350704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | D'ANDRIA | ||||||||
| AuthorizedOfficialFirstName: | GENCO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2143793300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDMARK SERVICES | ||||||||
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| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 48-03 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 48AA | 01 | CA | MEDI-CAL | OTHER | 48AA | 05 | CA | MEDICAID |