Provider Demographics
NPI:1780961920
Name:ST. MONICA'S OUTREACH CENTER FOR ADDICTIVE DISORDERS
Entity type:Organization
Organization Name:ST. MONICA'S OUTREACH CENTER FOR ADDICTIVE DISORDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHERIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-779-4756
Mailing Address - Street 1:1703 E 29TH ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-1406
Mailing Address - Country:US
Mailing Address - Phone:979-779-4756
Mailing Address - Fax:979-823-3018
Practice Address - Street 1:1703 E 29TH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-1406
Practice Address - Country:US
Practice Address - Phone:979-779-4756
Practice Address - Fax:979-823-3018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3474-3475261QM1300X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3474-3475OtherTEXAS DEPARTMENT OF STATE HEALTH SERVICES