Basic Information
| Provider Information | |||||||||
| NPI: | 1770913287 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDMARK TREATMENT CENTERS OF GEORGIA, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDMARK TREATMENT CENTERS COLUMBUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 1301 WYNNTON CT | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319062140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065764033 | ||||||||
| FaxNumber: | 7065764230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2013 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | D'ANDRIA | ||||||||
| AuthorizedOfficialFirstName: | GENCO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2143793300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDMARK SERVICES,INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 0000000 | GA | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QR0405X | NTO001011 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | NTP001011 | 01 | GA | NARCOTIC TREATMENT PROGRAM PERMIT | OTHER |