Provider Demographics
NPI:1912233826
Name:MERRIMACK RIVER MEDICAL SERVICES, INC.
Entity type:Organization
Organization Name:MERRIMACK RIVER MEDICAL SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP, TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JARVIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-379-3300
Mailing Address - Street 1:1720 LAKEPOINTE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-6458
Mailing Address - Country:US
Mailing Address - Phone:214-379-3300
Mailing Address - Fax:214-853-9018
Practice Address - Street 1:2300 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1908
Practice Address - Country:US
Practice Address - Phone:207-221-2292
Practice Address - Fax:207-221-2297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-28
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME151640000Medicaid