Basic Information
| Provider Information | |||||||||
| NPI: | 1487191235 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SH DETOX HOUSTON, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SERENITY HOUSE DETOX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2070 | ||||||||
| Address2: | |||||||||
| City: | HALLANDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330082070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543367747 | ||||||||
| FaxNumber: | 9542122328 | ||||||||
| Practice Location | |||||||||
| Address1: | 9714 S GESSNER RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770711004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8322403024 | ||||||||
| FaxNumber: | 9542122328 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2017 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUTLER | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF LCC | ||||||||
| AuthorizedOfficialTelephone: | 4108078471 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | FL | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.