Healthcare Provider Details

I. General information

NPI: 1659616647
Provider Name (Legal Business Name): GALLUS DETOX DALLAS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2012
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26791 US HIGHWAY 380 E
AUBREY TX
76227-7654
US

IV. Provider business mailing address

134 S GRANITE ST
PRESCOTT AZ
86303-4710
US

V. Phone/Fax

Practice location:
  • Phone: 281-277-0911
  • Fax:
Mailing address:
  • Phone: 928-227-2300
  • Fax: 928-445-1416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: PATRICK JOHN GALLUS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 928-227-2300