Healthcare Provider Details

I. General information

NPI: 1942704200
Provider Name (Legal Business Name): IVY GARDENS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOREST VILLAGE CIR
LA MARQUE TX
77568-1504
US

IV. Provider business mailing address

500 FOREST VILLAGE CIR
LA MARQUE TX
77568-1504
US

V. Phone/Fax

Practice location:
  • Phone: 409-256-5435
  • Fax:
Mailing address:
  • Phone: 409-256-5435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: KATRINA BANKS
Title or Position: C.E.O.
Credential:
Phone: 409-256-5435