MEDICARE: KENMAR RESIDENTIAL HCS SERVICES INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	001007619	TX

General Provider Information

NPI Number	:	1104030436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENMAR RESIDENTIAL HCS SERVICES INC.

Provider Business Mailing Address
First Line	:	555 ROUND ROCK WEST DR # F-360
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78681-5052
Country	:	US
Telephone Number	:	512-334-9192
Fax Number	:

Provider Business Practice Location Address
First Line	:	555 ROUND ROCK WEST DR # F-360
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78681-5052
Country	:	US
Telephone Number	:	512-334-9192
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AMANDA PEAKES-TAYLOR
Credential	:
Telephone Number	:	713-927-9920

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	10/24/2019

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