Provider Demographics
NPI:1023002425
Name:EAST TEXAS TREATMENT CENTER
Entity Type:Organization
Organization Name:EAST TEXAS TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-984-5571
Mailing Address - Street 1:1200 DUDLEY RD
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-3306
Mailing Address - Country:US
Mailing Address - Phone:903-984-5571
Mailing Address - Fax:903-984-1913
Practice Address - Street 1:1200 DUDLEY RD
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3306
Practice Address - Country:US
Practice Address - Phone:903-984-5571
Practice Address - Fax:903-984-1913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX605680000225100000X
TX261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)Group - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121835602Medicaid
TX00FM94Medicare ID - Type UnspecifiedPART B
TX121835602Medicaid