Provider Demographics
NPI:1265024566
Name:MALLARD LAKE RANCH DETOX CENTER, LLC
Entity Type:Organization
Organization Name:MALLARD LAKE RANCH DETOX CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-444-0614
Mailing Address - Street 1:P.O. BOX 1104
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77347-1104
Mailing Address - Country:US
Mailing Address - Phone:713-444-0614
Mailing Address - Fax:281-781-2526
Practice Address - Street 1:18407 HOPFE RD.
Practice Address - Street 2:
Practice Address - City:HOCKLEY
Practice Address - State:TX
Practice Address - Zip Code:77447-7119
Practice Address - Country:US
Practice Address - Phone:936-800-8025
Practice Address - Fax:281-781-2526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-08
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder