=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114734977
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. GENEVIEVE DETOX AND MAINTENANCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2024
-----------------------------------------------------
Last Update Date | 04/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 141 BRAZOSPORT BLVD N
-----------------------------------------------------
City | CLUTE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77531-3745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-265-0705
-----------------------------------------------------
Fax | 979-265-1178
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 141 BRAZOSPORT BLVD N
-----------------------------------------------------
City | CLUTE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77531-3745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-265-0705
-----------------------------------------------------
Fax | 979-265-1178
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | IKENNA OBUEKWE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-248-5582
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM2800X
-----------------------------------------------------
Taxonomy Name | Methadone Clinic
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------