=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174054795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNCONDITIONAL CARE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2017
-----------------------------------------------------
Last Update Date | 03/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 E HOUSTON ST FL 7
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78205-2991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-655-7072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5310 PEDERSON ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77033-3247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-655-7072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ANDRE GARRISON
-----------------------------------------------------
Credential | LCDC
-----------------------------------------------------
Telephone | 770-655-7072
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 3908
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------