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General NPI Number Information
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NPI Number | 1265615462
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Entity Type | Organization
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Legal Business Name | HUNTSVILLE CLINIC, INC
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Dates
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Enumeration Date | 12/11/2007
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Last Update Date | 04/20/2012
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Provider Practice Location Address
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Address Line | 829 10TH ST
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City | HUNTSVILLE
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State | TX
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Zip | 77320-4721
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Country | US
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Telephone | 936-291-9172
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Fax | 936-291-7156
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Provider Business Mailing Address
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Address Line | 829 10TH ST
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City | HUNTSVILLE
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State | TX
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Zip | 77320-4721
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Country | US
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Telephone | 936-291-9172
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Fax |
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Authorized Official
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Title or Position | CEO/PROGRAM SPONSOR
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Name | MS. STACEY RAE HARRIS
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Credential | L.C.D.C.
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Telephone | 936-524-2140
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2800X
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Taxonomy Name | Methadone Clinic
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License Number | TX10096M
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License Number State | TX
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