Provider Demographics
NPI:1659616647
Name:GALLUS DETOX DALLAS LLC
Entity Type:Organization
Organization Name:GALLUS DETOX DALLAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:GALLUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-227-2300
Mailing Address - Street 1:134 S GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-4710
Mailing Address - Country:US
Mailing Address - Phone:928-227-2300
Mailing Address - Fax:928-445-1416
Practice Address - Street 1:26791 US HIGHWAY 380 E
Practice Address - Street 2:
Practice Address - City:AUBREY
Practice Address - State:TX
Practice Address - Zip Code:76227-7654
Practice Address - Country:US
Practice Address - Phone:281-277-0911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-03
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical ToxicologyGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty