Healthcare Provider Details

I. General information

NPI: 1487103826
Provider Name (Legal Business Name): CIVITAS DRA 2016 MANAGMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3735 IRA E WOODS AVE
GRAPEVINE TX
76051-4213
US

IV. Provider business mailing address

3735 IRA E WOODS AVE
GRAPEVINE TX
76051-4213
US

V. Phone/Fax

Practice location:
  • Phone: 817-442-0505
  • Fax: 817-386-8324
Mailing address:
  • Phone: 817-442-0505
  • Fax: 817-386-8324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number140585
License Number StateTX

VIII. Authorized Official

Name: LAWRENCE WAYNE POWELL JR.
Title or Position: PRESIDENT
Credential:
Phone: 817-386-8888