Healthcare Provider Details

I. General information

NPI: 1497026827
Provider Name (Legal Business Name): STRAWBERRY LANE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2012
Last Update Date: 01/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 OAKLAND LN
CONROE TX
77302-1216
US

IV. Provider business mailing address

417 OAKLAND LN
CONROE TX
77302-1216
US

V. Phone/Fax

Practice location:
  • Phone: 936-355-1272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number209506
License Number StateTX

VIII. Authorized Official

Name: TAMMY BALDWIN
Title or Position: COTA
Credential:
Phone: 936-355-1272