Basic Information
| Provider Information | |||||||||
| NPI: | 1770781106 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDMARK TREATMENT CENTERS OF TEXAS 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: | 5201 MCCART AVE | ||||||||
| Address2: | SUITE H | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761153711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172078700 | ||||||||
| FaxNumber: | 8172078778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2007 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | D'ANDRIA | ||||||||
| AuthorizedOfficialFirstName: | GENCO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2143793300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 1000027 | TX | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QR0405X | 1000027 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 285947202 | 05 | TX | MEDICAID | 1000027 | 01 | TX | LICENSE | OTHER |