Healthcare Provider Details

I. General information

NPI: 1043396013
Provider Name (Legal Business Name): BRENDA'S DEVINE HERITAGE RESIDENTIAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 BRISCOE AVE
DEVINE TX
78016
US

IV. Provider business mailing address

PO BOX 224
DEVINE TX
78016-0224
US

V. Phone/Fax

Practice location:
  • Phone: 830-665-2000
  • Fax: 830-663-2832
Mailing address:
  • Phone: 210-387-7515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number114652
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: BRENDA JOYCE BURFORD
Title or Position: OWNER
Credential:
Phone: 210-387-7515