Provider Demographics
NPI:1265615462
Name:HUNTSVILLE CLINIC, INC
Entity type:Organization
Organization Name:HUNTSVILLE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PROGRAM SPONSOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC
Authorized Official - Phone:936-524-2140
Mailing Address - Street 1:829 10TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77320-4721
Mailing Address - Country:US
Mailing Address - Phone:936-291-9172
Mailing Address - Fax:
Practice Address - Street 1:829 10TH ST
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77320-4721
Practice Address - Country:US
Practice Address - Phone:936-291-9172
Practice Address - Fax:936-291-7156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX10096M261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG00249Medicare UPIN