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General NPI Number Information
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NPI Number | 1235565797
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Entity Type | Organization
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Legal Business Name | PRAIRIE HARBOR, LLC
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Dates
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Enumeration Date | 09/16/2013
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Last Update Date | 02/28/2014
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Provider Practice Location Address
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Address Line | 7146 HIGHWAY 60
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City | WALLIS
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State | TX
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Zip | 77485-9507
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Country | US
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Telephone | 979-217-1581
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 517
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City | WALLIS
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State | TX
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Zip | 77485-0517
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | RANDALL BRYANT
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Credential |
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Telephone | 979-217-1581
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number |
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License Number State |
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