=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134556798
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WTCR ABILENE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2013
-----------------------------------------------------
Last Update Date | 04/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 S LEGGETT
-----------------------------------------------------
City | ABILENE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79605-1628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-670-9339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 303249
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78703-0055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | IVAN GARCIA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 325-670-9339
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2800X
-----------------------------------------------------
Taxonomy Name | Methadone Clinic
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------