MEDICARE: SOLARA BEHAVIORAL HEALTH SAN ANTONIO, LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QC1500X	Community Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124073150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOLARA BEHAVIORAL HEALTH SAN ANTONIO, LLP

Provider Business Mailing Address
First Line	:	1975 BABCOCK RD
Second Line	:	SUITE 140
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-4585
Country	:	US
Telephone Number	:	281-914-1012
Fax Number	:	682-831-9625

Provider Business Practice Location Address
First Line	:	1975 BABCOCK RD
Second Line	:	SUITE 140
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-4585
Country	:	US
Telephone Number	:	281-914-1012
Fax Number	:	682-831-9625

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. NATHAN DANIEL INGRAM
Credential	:
Telephone Number	:	281-914-1012

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	09/26/2012

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