Provider Demographics
NPI:1629689559
Name:BANYAN TEXAS, LLC
Entity type:Organization
Organization Name:BANYAN TEXAS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-533-7705
Mailing Address - Street 1:225 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-4319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:954-781-7173
Practice Address - Street 1:4168 COUNTY ROAD 444
Practice Address - Street 2:
Practice Address - City:WAELDER
Practice Address - State:TX
Practice Address - Zip Code:78959-5328
Practice Address - Country:US
Practice Address - Phone:830-283-3003
Practice Address - Fax:830-522-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4238503Medicaid