Basic Information
Provider Information | |||||||||
NPI: | 1851453500 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEDMARK TREATMENT CENTERS- STOCKTON, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1720 LAKEPOINTE DR STE 117 | ||||||||
Address2: |   | ||||||||
City: | LEWISVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 750576425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2143793300 | ||||||||
FaxNumber: | 2148539018 | ||||||||
Practice Location | |||||||||
Address1: | 1111 N EL DORADO STREET | ||||||||
Address2: |   | ||||||||
City: | STOCKTON | ||||||||
State: | CA | ||||||||
PostalCode: | 952021305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2099380228 | ||||||||
FaxNumber: | 2099380281 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/15/2006 | ||||||||
LastUpdateDate: | 04/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | D'ANDRIA | ||||||||
AuthorizedOfficialFirstName: | GILBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP, TREASURER | ||||||||
AuthorizedOfficialTelephone: | 2143793300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MEDMARK SERVICES, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 39-07 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
ID | Type | State | Issuer | Description | 48AC | 01 | CA | MEDI-CAL | OTHER | 48-AC | 05 | CA |   | MEDICAID |