Basic Information
| Provider Information | |||||||||
| NPI: | 1851506091 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE METRO TREATMENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14050 TOWN LOOP BLVD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328376190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073517080 | ||||||||
| FaxNumber: | 4073516930 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 NARRAGANSETT AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029073367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4019414488 | ||||||||
| FaxNumber: | 4019419797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 12/03/2007 | ||||||||
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| AuthorizedOfficialLastName: | KACZMAREK | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 4073517080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | CMC00033 | RI | N | Suppliers | Pharmacy | Clinic Pharmacy | 251S00000X | 614, 614.1 | RI | Y | Agencies | Community/Behavioral Health |
No ID Information.