Basic Information
| Provider Information | |||||||||
| NPI: | 1851699631 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST TREATMENT CENTERS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NET TREATMENT SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 499 N 5TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191234005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154517000 | ||||||||
| FaxNumber: | 2159256897 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S 7TH ST | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180424362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154517000 | ||||||||
| FaxNumber: | 2159256897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2011 | ||||||||
| LastUpdateDate: | 04/14/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NOEL | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2154517000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 487040 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 100757855 | 05 | PA | MEDICAID | 100757855 | 01 | PA | MAGELLAN HEALTH CHOICES | OTHER |