Provider Demographics
NPI:1215308242
Name:BORDER REGION MHMR YOUTH EMPOWERMENT SERVICES WAIVER
Entity type:Organization
Organization Name:BORDER REGION MHMR YOUTH EMPOWERMENT SERVICES WAIVER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:CASTILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-794-3000
Mailing Address - Street 1:1500 PAPPAS ST
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-1701
Mailing Address - Country:US
Mailing Address - Phone:956-794-3000
Mailing Address - Fax:956-794-3325
Practice Address - Street 1:1500 PAPPAS ST
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-1701
Practice Address - Country:US
Practice Address - Phone:956-794-3000
Practice Address - Fax:956-794-3325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121989103Medicaid