MEDICARE: AN OPEN DOOR GROUP HOME, 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

General Provider Information

NPI Number	:	1730479973
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AN OPEN DOOR GROUP HOME, INC

Provider Business Mailing Address
First Line	:	7840 WHITNEY LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-6168
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7840 WHITNEY LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-6168
Country	:	US
Telephone Number	:	817-862-3495
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KATHRYN BAILEY
Credential	:
Telephone Number	:	817-862-3495

Provider Enumeration Date	:	04/08/2011
Last Update Date	:	04/08/2011

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