Provider Demographics
NPI:1003121526
Name:HUNTSVILLE CLINIC, INC.
Entity Type:Organization
Organization Name:HUNTSVILLE CLINIC, INC.
Other - Org Name:CONROE TREATMENT & RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC
Authorized Official - Phone:936-441-9172
Mailing Address - Street 1:501 EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77301-1826
Mailing Address - Country:US
Mailing Address - Phone:936-441-9172
Mailing Address - Fax:936-441-9177
Practice Address - Street 1:501 EVERETT ST
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-1826
Practice Address - Country:US
Practice Address - Phone:936-441-9172
Practice Address - Fax:936-441-9177
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HUNTSVILLE CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-09
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX-10235-M261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXNOT ISSUED YETOtherNOT YET ISSUED