MEDICARE: PADRE BEHAVIORAL HEALTH SYSTEM, 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	283Q00000X	Psychiatric Hospital	007165	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HH3978	OTHER	TX	BCBS CD
2	HH0978	OTHER	TX	BCBS PSYCH
3	HH6788	OTHER	TX	BCBS PARTIAL

General Provider Information

NPI Number	:	1588661060
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PADRE BEHAVIORAL HEALTH SYSTEM, LLC

Provider Business Mailing Address
First Line	:	6629 WOOLDRIDGE RD
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78414-2909
Country	:	US
Telephone Number	:	361-986-9444
Fax Number	:	361-986-1897

Provider Business Practice Location Address
First Line	:	6629 WOOLDRIDGE RD
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78414-2909
Country	:	US
Telephone Number	:	361-986-9444
Fax Number	:	361-986-1897

Authorized Official
Title or Position	:	CEO-CFO
Name	:	MR. JOHN SEWELL CROLEY
Credential	:
Telephone Number	:	361-986-9444

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	08/22/2020

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