MEDICARE: SH 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1932782836
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SH DETOX HOUSTON, LLC

Provider Business Mailing Address
First Line	:	10019 REISTERSTOWN RD FL 3
Second Line	:
City	:	OWINGS MILLS
State	:	MD
Zip	:	21117-3902
Country	:	US
Telephone Number	:	443-839-6928
Fax Number	:	443-269-0667

Provider Business Practice Location Address
First Line	:	1450 CAMPBELL RD STE 100&200
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77055-4667
Country	:	US
Telephone Number	:	832-240-3024
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	JESSIE COSTLEY
Credential	:
Telephone Number	:	443-839-6928

Provider Enumeration Date	:	04/29/2021
Last Update Date	:	09/15/2021

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