Healthcare Provider Details

I. General information

NPI: 1487955811
Provider Name (Legal Business Name): SAN GABRIEL RECOVERY RANCH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1443 COUNTY ROAD 103
GEORGETOWN TX
78626-3854
US

IV. Provider business mailing address

1443 COUNTY ROAD 103
GEORGETOWN TX
78626-3854
US

V. Phone/Fax

Practice location:
  • Phone: 512-561-5086
  • Fax: 512-692-2803
Mailing address:
  • Phone: 512-561-5086
  • Fax: 512-692-2803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number3338-3339
License Number StateTX

VIII. Authorized Official

Name: CATHERINE S OLIVER
Title or Position: CONTROLLER
Credential:
Phone: 512-561-0586