MEDICARE: CLEAR SPRINGS HEALTHCARE 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	276400000X	Substance Use Disorder Rehabilitation Hospital Unit	3551-3552	TX

General Provider Information

NPI Number	:	1467709089
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEAR SPRINGS HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	3662 PATTON LAKE RD
Second Line	:
City	:	AQUILLA
State	:	TX
Zip	:	76622-2590
Country	:	US
Telephone Number	:	469-209-6200
Fax Number	:	254-829-1122

Provider Business Practice Location Address
First Line	:	3662 PATTON LAKE RD
Second Line	:
City	:	AQUILLA
State	:	TX
Zip	:	76622-2590
Country	:	US
Telephone Number	:	469-209-6200
Fax Number	:	254-829-1122

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. JOHN S LACY
Credential	:
Telephone Number	:	469-209-6200

Provider Enumeration Date	:	08/14/2012
Last Update Date	:	08/14/2012

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