Healthcare Provider Details

I. General information

NPI: 1093899445
Provider Name (Legal Business Name): CLASSIC GROUP H OME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1454 SOMERCOTES LN
CHANNELVIEW TX
77530-2258
US

IV. Provider business mailing address

1454 SOMERCOTES LN
CHANNELVIEW TX
77530-2258
US

V. Phone/Fax

Practice location:
  • Phone: 281-452-4661
  • Fax: 281-452-4639
Mailing address:
  • Phone: 281-452-4661
  • Fax: 281-452-4639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number115384
License Number StateTX

VIII. Authorized Official

Name: MS. SHIRLEY ANN SHAW
Title or Position: OWNER
Credential:
Phone: 281-452-4661