Basic Information
| Provider Information | |||||||||
| NPI: | 1942779467 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POLARIS RENEWAL SERVICES, INC. | ||||||||
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| OtherOrganizationName: | POLARIS RENEWAL SERVCIES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 LAKEPOINTE DR STE 117 | ||||||||
| Address2: | |||||||||
| City: | LEWISVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750576425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143793300 | ||||||||
| FaxNumber: | 2148533018 | ||||||||
| Practice Location | |||||||||
| Address1: | 2262 UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | LEMONT FURNACE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 154561332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243238200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2018 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | D'ANDRIA | ||||||||
| AuthorizedOfficialFirstName: | GILBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2143793302 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | POLARIS RENEWAL SERVICES, INC. | ||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.