Healthcare Provider Details

I. General information

NPI: 1114165495
Provider Name (Legal Business Name): MR. RAYFIELD WAYNE JEFFERSON SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2009
Last Update Date: 01/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 FM 222
COLDSPRING TX
77331
US

IV. Provider business mailing address

PO BOX 142
COLDSPRING TX
77331-0142
US

V. Phone/Fax

Practice location:
  • Phone: 936-653-4113
  • Fax:
Mailing address:
  • Phone: 936-653-4113
  • 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 State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: