Provider Demographics
NPI:1457822538
Name:11817 LANDRUM INC
Entity type:Organization
Organization Name:11817 LANDRUM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:409-853-2273
Mailing Address - Street 1:1505 CORNERSTONE CT
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-3899
Mailing Address - Country:US
Mailing Address - Phone:409-299-8555
Mailing Address - Fax:
Practice Address - Street 1:1505 CORNERSTONE CT
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-3899
Practice Address - Country:US
Practice Address - Phone:409-299-8555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:11817 LANDRUM INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-16
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health