Provider Demographics
NPI:1396920880
Name:GULF SHORES OUTPATIENT SUBSTANCE CENTER
Entity type:Organization
Organization Name:GULF SHORES OUTPATIENT SUBSTANCE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:713-773-3443
Mailing Address - Street 1:9896 BISSONNET ST
Mailing Address - Street 2:250
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77036-8104
Mailing Address - Country:US
Mailing Address - Phone:713-773-3443
Mailing Address - Fax:713-773-3565
Practice Address - Street 1:9896 BISSONNET ST
Practice Address - Street 2:250
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-8104
Practice Address - Country:US
Practice Address - Phone:713-773-3443
Practice Address - Fax:713-773-3565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1684305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization