| Medmark Treatment Centers - Vallejo | |
|
1628 Broadway Street Vallejo CA 94590-2405 | |
| (707) 649-8300 | |
| (707) 649-8302 |
| Full Name | Medmark Treatment Centers - Vallejo |
|---|---|
| Speciality | Clinic/Center |
| Location | 1628 Broadway Street, Vallejo, California |
| Authorized Official Name and Position | Bruce Jarvie (VP, TREASURER) |
| Authorized Official Contact | 2143793300 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Medmark Treatment Centers - Vallejo 1720 Lakepointe Dr Ste 117 Lewisville TX 75057-6425 Ph: (214) 379-3300 | Medmark Treatment Centers - Vallejo 1628 Broadway Street Vallejo CA 94590-2405 Ph: (707) 649-8300 |
| NPI Number | 1154548535 |
|---|---|
| Provider Enumeration Date | 04/19/2007 |
| Last Update Date | 07/29/2024 |
| Certification Date | 07/29/2024 |
| Medicare PECOS PAC ID | 5294162046 |
|---|---|
| Medicare Enrollment ID | O20200217004930 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1154548535 | NPI | - | NPPES |
| 48-04 | Other | CA | OTP LICENSE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | 48-02 (California) | Secondary |
| 261QM2800X | Clinic/center - Methadone | 48-04 (California) | Primary |
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