Basic Information
| Provider Information | |||||||||
| NPI: | 1497985998 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADAPT FOUNDATION INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BRAZOS PLACE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 474 | ||||||||
| Address2: | |||||||||
| City: | ANGLETON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775160474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9792333826 | ||||||||
| FaxNumber: | 2813775870 | ||||||||
| Practice Location | |||||||||
| Address1: | 1103 N AVENUE H | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775414006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9792333826 | ||||||||
| FaxNumber: | 9792333708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2009 | ||||||||
| LastUpdateDate: | 12/12/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARDZINA | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8328922055 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCDC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 3994-3995 | TX | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 065443601 | 05 | TX | MEDICAID |