Provider Demographics
NPI:1114734977
Name:ST. GENEVIEVE DETOX AND MAINTENANCE
Entity type:Organization
Organization Name:ST. GENEVIEVE DETOX AND MAINTENANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:IKENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:OBUEKWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-248-5582
Mailing Address - Street 1:141 BRAZOSPORT BLVD N
Mailing Address - Street 2:
Mailing Address - City:CLUTE
Mailing Address - State:TX
Mailing Address - Zip Code:77531-3745
Mailing Address - Country:US
Mailing Address - Phone:979-265-0705
Mailing Address - Fax:979-265-1178
Practice Address - Street 1:141 BRAZOSPORT BLVD N
Practice Address - Street 2:
Practice Address - City:CLUTE
Practice Address - State:TX
Practice Address - Zip Code:77531-3745
Practice Address - Country:US
Practice Address - Phone:979-265-0705
Practice Address - Fax:979-265-1178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-16
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder