Healthcare Provider Details

I. General information

NPI: 1164693388
Provider Name (Legal Business Name): LIBERTY ISLAND ADULT DAY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2008
Last Update Date: 03/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9009 BOONE RD
HOUSTON TX
77099-2033
US

IV. Provider business mailing address

9009 BOONE RD
HOUSTON TX
77099-2033
US

V. Phone/Fax

Practice location:
  • Phone: 281-530-3735
  • Fax:
Mailing address:
  • Phone: 281-530-3735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateTX

VIII. Authorized Official

Name: MS. ARETHA JOHNSON
Title or Position: CEO
Credential: RN, BSN
Phone: 281-530-0000