MEDICARE: LIVING QUALITY MOMENTS 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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1205136801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVING QUALITY MOMENTS INC.

Provider Business Mailing Address
First Line	:	1019 W ENON AVE
Second Line	:	SUITE A
City	:	EVERMAN
State	:	TX
Zip	:	76140-3648
Country	:	US
Telephone Number	:	817-551-0559
Fax Number	:	817-551-0668

Provider Business Practice Location Address
First Line	:	320 AUTUMN PARK
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140-6524
Country	:	US
Telephone Number	:	817-551-0559
Fax Number	:	817-551-0668

Authorized Official
Title or Position	:	CEO/PRESIDENT/PROGRAM DIRECTOR
Name	:	LISA QUEENESTER MARONEY
Credential	:
Telephone Number	:	817-565-5984

Provider Enumeration Date	:	10/28/2010
Last Update Date	:	10/28/2010

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