Provider Demographics
NPI:1235565797
Name:PRAIRIE HARBOR, LLC
Entity Type:Organization
Organization Name:PRAIRIE HARBOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-217-1581
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:WALLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77485-0517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7146 HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:WALLIS
Practice Address - State:TX
Practice Address - Zip Code:77485-9507
Practice Address - Country:US
Practice Address - Phone:979-217-1581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-16
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children