Provider Demographics
NPI:1992036156
Name:SEQUEL TSI OF PAINT ROCK VALLEY, LLC
Entity Type:Organization
Organization Name:SEQUEL TSI OF PAINT ROCK VALLEY, LLC
Other - Org Name:PAINT ROCK VALLEY GIRLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:STUPAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-419-8913
Mailing Address - Street 1:3890 COUNTY ROAD 20
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:AL
Mailing Address - Zip Code:35774-7423
Mailing Address - Country:US
Mailing Address - Phone:256-776-2503
Mailing Address - Fax:256-776-2561
Practice Address - Street 1:3890 COUNTY ROAD 20
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:AL
Practice Address - Zip Code:35774-7423
Practice Address - Country:US
Practice Address - Phone:256-776-2503
Practice Address - Fax:256-776-2561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children