Healthcare Provider Details

I. General information

NPI: 1396023784
Provider Name (Legal Business Name): SR GOLDEN HEART PROVIDER CARE AND TRANSPORTATION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2011
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7100 REGENCY SQUARE BLVD SUITE 203-5
HOUSTON TX
77036-3202
US

IV. Provider business mailing address

7100 REGENCY SQUARE BLVD SUITE 203-5
HOUSTON TX
77036-3202
US

V. Phone/Fax

Practice location:
  • Phone: 713-784-2480
  • Fax: 713-784-2860
Mailing address:
  • Phone: 713-784-2480
  • Fax: 713-784-2860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MR. JEVAO FAYIA SAFFA
Title or Position: PROGRAM MANAGER
Credential:
Phone: 713-784-2480