Provider Demographics
NPI:1689392987
Name:DALLAS DETOX CENTER
Entity Type:Organization
Organization Name:DALLAS DETOX CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:PETRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-788-4460
Mailing Address - Street 1:100 MARIAH DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-7408
Mailing Address - Country:US
Mailing Address - Phone:888-979-9503
Mailing Address - Fax:
Practice Address - Street 1:100 MARIAH DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76087-7408
Practice Address - Country:US
Practice Address - Phone:888-979-9503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4814-4815OtherPRIVATE FUNDING