Provider Demographics
NPI:1205105103
Name:GARZA THERAPEUTIC, LLC
Entity type:Organization
Organization Name:GARZA THERAPEUTIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLININCAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARZA
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:651-324-8341
Mailing Address - Street 1:33 WENTWORTH AVE E
Mailing Address - Street 2:#292
Mailing Address - City:WEST ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-3431
Mailing Address - Country:US
Mailing Address - Phone:651-917-8698
Mailing Address - Fax:866-879-4712
Practice Address - Street 1:33 E. WENTWROTH AVE.
Practice Address - Street 2:#292
Practice Address - City:WEST ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:651-917-8698
Practice Address - Fax:866-879-4712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12842251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN900002696OtherMEDICARE ID