Basic Information
| Provider Information | |||||||||
| NPI: | 1871949487 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYLAND TREATMENT CENTERS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MOUNTAIN MANOR TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 FREDERICK AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212293618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102331400 | ||||||||
| FaxNumber: | 4102331666 | ||||||||
| Practice Location | |||||||||
| Address1: | 9701 KEYSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | EMMITSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217278619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014472360 | ||||||||
| FaxNumber: | 3014473673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2016 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOLEK | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACTS COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2404013062 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARYLAND TREATMENT CENTERS, INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 13953 | MD | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 13953 | 01 | MD | LICENSE | OTHER |