Provider Demographics
NPI:1962559252
Name:SHORELINE, INC.
Entity type:Organization
Organization Name:SHORELINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-528-3356
Mailing Address - Street 1:1220 GREGORY ST
Mailing Address - Street 2:
Mailing Address - City:TAFT
Mailing Address - State:TX
Mailing Address - Zip Code:78390-3044
Mailing Address - Country:US
Mailing Address - Phone:361-528-3356
Mailing Address - Fax:361-528-3249
Practice Address - Street 1:1220 GREGORY ST.
Practice Address - Street 2:
Practice Address - City:TAFT
Practice Address - State:TX
Practice Address - Zip Code:78390-3044
Practice Address - Country:US
Practice Address - Phone:361-528-3356
Practice Address - Fax:361-528-3249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084P0800X, 261QR0405X
TX481A3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX065220801Medicaid