Healthcare Provider Details

I. General information

NPI: 1942041785
Provider Name (Legal Business Name): CISSY'S ELDERLY LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 ANDOVER ST
FORT WORTH TX
76114-1848
US

IV. Provider business mailing address

145 BIG SANDY LN
LANCASTER TX
75146-2919
US

V. Phone/Fax

Practice location:
  • Phone: 305-363-9635
  • Fax:
Mailing address:
  • Phone: 305-363-9635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. CHRISTINA ALEXANDRIA REID
Title or Position: OWNER
Credential:
Phone: 305-363-9635