MEDICARE: GALLUS DETOX HOUSTON LLC

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	324500000X	Substance Abuse Rehabilitation Facility	BH3852	AZ

General Provider Information

NPI Number	:	1235488164
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GALLUS DETOX HOUSTON LLC

Provider Business Mailing Address
First Line	:	134 S GRANITE ST
Second Line	:
City	:	PRESCOTT
State	:	AZ
Zip	:	86303-4710
Country	:	US
Telephone Number	:	928-227-2300
Fax Number	:

Provider Business Practice Location Address
First Line	:	16000 SOUTHWEST FWY
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77479-2673
Country	:	US
Telephone Number	:	928-227-2300
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. PATRICK JOHN GALLUS
Credential	:	DO
Telephone Number	:	928-227-2300

Provider Enumeration Date	:	09/06/2012
Last Update Date	:	09/06/2012

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