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General NPI Number Information
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NPI Number | 1053274910
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Entity Type | Organization
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Legal Business Name | FORT WORTH DETOX LLC
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Dates
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Enumeration Date | 12/08/2025
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Last Update Date | 12/08/2025
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Provider Practice Location Address
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Address Line | 101 MARIAH DR
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City | WEATHERFORD
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State | TX
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Zip | 76087-7400
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Country | US
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Telephone | 978-440-3200
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Fax | 323-529-8134
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Provider Business Mailing Address
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Address Line | 621 NW 53RD ST STE 370
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City | BOCA RATON
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State | FL
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Zip | 33487-8241
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Country | US
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Telephone | 978-440-3200
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Fax | 323-529-8134
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Authorized Official
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Title or Position | CEO
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Name | NICHOLAS ADAM PETRILLO
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Credential |
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Telephone | 972-440-3200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number |
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License Number State |
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