Provider Demographics
NPI:1083233498
Name:THE POLO GROUP LLC
Entity Type:Organization
Organization Name:THE POLO GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:POLO
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC
Authorized Official - Phone:972-906-9112
Mailing Address - Street 1:1626 W HIGHWAY 287 BUSINESS STE 101
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-4728
Mailing Address - Country:US
Mailing Address - Phone:972-906-9112
Mailing Address - Fax:972-906-9112
Practice Address - Street 1:1626 W HIGHWAY 287 BUSINESS STE 101
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-4728
Practice Address - Country:US
Practice Address - Phone:972-906-9112
Practice Address - Fax:972-906-9112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1013287721Medicaid