1053650234 NPI number — BRAZOS INTENSIVE OUTPATIENT PROGRAM, LLC

Table of content: (NPI 1053650234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053650234 NPI number — BRAZOS INTENSIVE OUTPATIENT PROGRAM, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRAZOS INTENSIVE OUTPATIENT PROGRAM, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053650234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1114 LOST CREEK BLVD
Provider Second Line Business Mailing Address:
STE 500
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78746-6300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-308-6032
Provider Business Mailing Address Fax Number:
512-306-9188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
257 FM 927 CR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76671-1111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-775-4088
Provider Business Practice Location Address Fax Number:
267-795-9510
Provider Enumeration Date:
02/07/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PATTERSON
Authorized Official First Name:
BEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
254-775-4088

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  3593-3594 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3593-3594 . This is a "FACILITY LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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