=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053693820
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERVICE ORGANIZATION BENEFITING RECOVERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2011
-----------------------------------------------------
Last Update Date | 05/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12955 MEMORIAL DR STE F225
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77079-7302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-270-6753
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9337B KATY FWY # 289
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77024-1515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-270-6753
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. JOHN C CATES
-----------------------------------------------------
Credential | LCDC
-----------------------------------------------------
Telephone | 713-459-9427
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 3354-3355
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 3354-3355
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------