| NPI | 1649786260 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | AMY MARIE NIEMAN Director Of Credentialing 833-510-4357 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder |
| Additional Taxonomies | 261QM2800X Clinic/Center, Methadone Clinic |
| 207RA0401X Internal Medicine, Addiction Medicine | |
| 291U00000X Clinical Medical Laboratory | |
| 251S00000X Community/Behavioral Health | |
| Enumeration Date | 2017-12-19 |
| Last Update Date | 2026-02-12 |