Basic Information
Provider Information | |||||||||
NPI: | 1023433679 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EDUCARE COMMUNITY LIVING CORPORATION - GULF COAST | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DESTINY GH | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9901 LINN STATION RD | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402233808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5023942100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8002 FAWN TERRACE DR | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770712723 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5023942100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2014 | ||||||||
LastUpdateDate: | 02/19/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OMBRES | ||||||||
AuthorizedOfficialFirstName: | DEENA | ||||||||
AuthorizedOfficialMiddleName: | G. | ||||||||
AuthorizedOfficialTitleorPosition: | ASSOC. GEN. COUNSEL/PRIVACY OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5023942100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X |   | TX | Y |   | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |   |
No ID Information.