MEDICARE: NGU HOME, NEW LIFE

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1922418219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NGU HOME, NEW LIFE

Provider Business Mailing Address
First Line	:	PO BOX 683168
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77268-3168
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4166 SURREYDON DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77014-2152
Country	:	US
Telephone Number	:	713-584-9760
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NYSSA NGU
Credential	:
Telephone Number	:	713-584-9760

Provider Enumeration Date	:	05/07/2014
Last Update Date	:	05/07/2014

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