Healthcare Provider Details

I. General information

NPI: 1841360542
Provider Name (Legal Business Name): CASA DE AMISTAD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1933 FREDERICKSBURG RD SUITE 101
SAN ANTONIO TX
78201-4457
US

IV. Provider business mailing address

1933 FREDERICKSBURG RD SUITE 101
SAN ANTONIO TX
78201-4457
US

V. Phone/Fax

Practice location:
  • Phone: 210-737-6955
  • Fax: 210-737-6956
Mailing address:
  • Phone: 210-737-6955
  • Fax: 210-737-6956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number118537
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARIELA ANGULO
Title or Position: DIRECTOR
Credential: RN
Phone: 210-737-6955