Provider Demographics
NPI:1912296013
Name:MHMR AUTHORITY OF BRAZOS VALLEY
Entity Type:Organization
Organization Name:MHMR AUTHORITY OF BRAZOS VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-822-6467
Mailing Address - Street 1:PO BOX 4588
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77805-4588
Mailing Address - Country:US
Mailing Address - Phone:979-822-6467
Mailing Address - Fax:979-821-9448
Practice Address - Street 1:804 S TEXAS AVE
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77803-3946
Practice Address - Country:US
Practice Address - Phone:979-822-6467
Practice Address - Fax:979-821-9448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJH49Medicare UPIN