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General NPI Number Information
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NPI Number | 1487882254
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Entity Type | Organization
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Legal Business Name | SPIRIT LODGE
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Dates
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Enumeration Date | 06/30/2009
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Last Update Date | 06/30/2009
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Provider Practice Location Address
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Address Line | 840 COUNTY ROAD 420
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City | SPICEWOOD
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State | TX
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Zip | 78669-3077
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Country | US
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Telephone | 830-798-2220
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Fax | 830-798-2225
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Provider Business Mailing Address
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Address Line | 840 COUNTY ROAD 420
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City | SPICEWOOD
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State | TX
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Zip | 78669-3077
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Country | US
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Telephone | 830-798-2220
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Fax | 830-798-2225
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Authorized Official
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Title or Position | CORP. DIRECTOR OF OUTCOMES IMPROVEM
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Name | LEANA M GADBOIS-SILLS
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Credential | BS
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Telephone | 713-933-1391
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 562-3063
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License Number State | TX
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