Healthcare Provider Details

I. General information

NPI: 1538532429
Provider Name (Legal Business Name): MISSION ROAD DEVELOPMENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8706 MISSION RD
SAN ANTONIO TX
78214-3140
US

IV. Provider business mailing address

8706 MISSION RD
SAN ANTONIO TX
78214-3140
US

V. Phone/Fax

Practice location:
  • Phone: 210-924-9265
  • Fax: 210-922-6006
Mailing address:
  • Phone: 210-924-9265
  • Fax: 210-922-6006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number123357
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number123265
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number117405
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number117406
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number016040
License Number StateTX

VIII. Authorized Official

Name: LORA S. BUTLER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 210-334-2437