Basic Information
| Provider Information | |||||||||
| NPI: | 1538505649 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VCPHCS XXI, LLC | ||||||||
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| OtherOrganizationName: | BHG MEMPHIS NORTH TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5001 SPRING VALLEY ROAD | ||||||||
| Address2: | SUITE 600 EAST | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752443946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143656100 | ||||||||
| FaxNumber: | 2143656150 | ||||||||
| Practice Location | |||||||||
| Address1: | 2165 SPICER CV STE 5 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381345623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013727878 | ||||||||
| FaxNumber: | 9013729298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2013 | ||||||||
| LastUpdateDate: | 02/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | GASAWAY | ||||||||
| AuthorizedOfficialFirstName: | JEMECE | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 2143656126 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM2800X | L000000011850 | TN | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.