Provider Demographics
NPI:1598306862
Name:ETHOS PRAIRIE, LLC
Entity Type:Organization
Organization Name:ETHOS PRAIRIE, LLC
Other - Org Name:THE PRAIRIE RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-436-4260
Mailing Address - Street 1:5808 WAGNER RD
Mailing Address - Street 2:
Mailing Address - City:ROUND TOP
Mailing Address - State:TX
Mailing Address - Zip Code:78954-5075
Mailing Address - Country:US
Mailing Address - Phone:979-836-4975
Mailing Address - Fax:
Practice Address - Street 1:5808 WAGNER RD
Practice Address - Street 2:
Practice Address - City:ROUND TOP
Practice Address - State:TX
Practice Address - Zip Code:78954-5075
Practice Address - Country:US
Practice Address - Phone:979-836-4975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-08
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder