MEDICARE: JIMMIE L SMITH

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	000456	TX

General Provider Information

NPI Number	:	1336314038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JIMMIE L SMITH

Provider Business Mailing Address
First Line	:	17188 OAK GROVE LN
Second Line	:
City	:	NEW CANEY
State	:	TX
Zip	:	77357-3391
Country	:	US
Telephone Number	:	281-429-1838
Fax Number	:	281-432-1820

Provider Business Practice Location Address
First Line	:	18350 E HIGHWAY 105 STE A
Second Line	:
City	:	CLEVELAND
State	:	TX
Zip	:	77328-2440
Country	:	US
Telephone Number	:	281-432-1810
Fax Number	:	281-432-1820

Authorized Official
Title or Position	:	BOOKKEEPER
Name	:	MRS. JUDY L SMITH
Credential	:
Telephone Number	:	281-432-1810

Provider Enumeration Date	:	04/24/2008
Last Update Date	:	04/24/2008

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