Healthcare Provider Details

I. General information

NPI: 1780962530
Provider Name (Legal Business Name): IMMANUEL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2011
Last Update Date: 07/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 OAKMONT DR
LANCASTER TX
75134-2024
US

IV. Provider business mailing address

2709 OAKMONT DR
LANCASTER TX
75134-2024
US

V. Phone/Fax

Practice location:
  • Phone: 469-386-4428
  • Fax:
Mailing address:
  • Phone:
  • 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 Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER JENKINS
Title or Position: OWNER
Credential:
Phone: 469-386-4428