Provider Demographics
NPI:1205022159
Name:MESQUITE TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:MESQUITE TREATMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:LISA
Authorized Official - Last Name:CAVAZOS
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC
Authorized Official - Phone:956-428-2100
Mailing Address - Street 1:513 E JACKSON ST STE 221
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-6877
Mailing Address - Country:US
Mailing Address - Phone:956-428-2100
Mailing Address - Fax:
Practice Address - Street 1:513 E JACKSON ST STE 221
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-6877
Practice Address - Country:US
Practice Address - Phone:956-428-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2502-A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182590301Medicaid