Basic Information
| Provider Information | |||||||||
| NPI: | 1780890327 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO TREATMENT OF FLORIDA, LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEW SEASON TREATMENT CENTER 12 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 MAITLAND CENTER PARKWAY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327514174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073517080 | ||||||||
| FaxNumber: | 4073516930 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 SW 12TH AVE STE 100-101 | ||||||||
| Address2: | |||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330693500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547829774 | ||||||||
| FaxNumber: | 9547823843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4073517080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | METRO TREATMENT OF FLORIDA, LP | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1006AD346101 | FL | N | Agencies | Community/Behavioral Health | 3336C0002X | PH 18121 | FL | N | Suppliers | Pharmacy | Clinic Pharmacy | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.