Basic Information
| Provider Information | |||||||||
| NPI: | 1790146942 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VILLAGE LIFE CENTER TEXAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9660 FALLS OF NEUSE ROAD | ||||||||
| Address2: | SUITE 138, #273 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197238799 | ||||||||
| FaxNumber: | 8668259703 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 CRAWFORD ST STE 208 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770028941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137399725 | ||||||||
| FaxNumber: | 8662423803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2016 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | CARR-BROWN | ||||||||
| AuthorizedOfficialFirstName: | AYANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9197238799 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0829 | 05 | TX | MEDICAID |