Provider Demographics
NPI:1952174419
Name:CITY OF LAREDO DETOXIFICATION DEPARTMENT
Entity Type:Organization
Organization Name:CITY OF LAREDO DETOXIFICATION DEPARTMENT
Other - Org Name:ROOTS RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DETOXIFICATION DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAN JUANA
Authorized Official - Middle Name:VIVIANA
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, DHA, LCDC
Authorized Official - Phone:956-679-2826
Mailing Address - Street 1:1300 CHICAGO ST.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78040
Mailing Address - Country:US
Mailing Address - Phone:956-679-2826
Mailing Address - Fax:
Practice Address - Street 1:1300 CHICAGO ST.
Practice Address - Street 2:SUITE 101
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78040
Practice Address - Country:US
Practice Address - Phone:956-679-2826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF LAREDO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-11-06
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty