Healthcare Provider Details

I. General information

NPI: 1063616548
Provider Name (Legal Business Name): GOLDEN TRIANGLE LIVING CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 S 4TH ST
BEAUMONT TX
77701-7912
US

IV. Provider business mailing address

2750 S 4TH ST
BEAUMONT TX
77701-7912
US

V. Phone/Fax

Practice location:
  • Phone: 409-832-4112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateTX

VIII. Authorized Official

Name: MR. RICHARD BENNETT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 409-791-4398