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General NPI Number Information
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NPI Number | 1407134448
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL HOME DETOX
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Dates
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Enumeration Date | 07/25/2011
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Last Update Date | 07/25/2011
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Provider Practice Location Address
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Address Line | 8104 COUNTY ROAD 6500
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City | LUBBOCK
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State | TX
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Zip | 79416-9557
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Country | US
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Telephone | 806-773-6575
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Fax |
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Provider Business Mailing Address
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Address Line | 8104 COUNTY ROAD 6500
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City | LUBBOCK
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State | TX
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Zip | 79416-9557
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Country | US
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Telephone | 806-773-6575
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MRS. COURTNEY CAROLE FULLER
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Credential | BSN, RN
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Telephone | 806-773-6575
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 671297
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License Number State | TX
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