Healthcare Provider Details

I. General information

NPI: 1255418653
Provider Name (Legal Business Name): MISSION ROAD DEVELOPMENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 KOPPLOW PL
SAN ANTONIO TX
78221-2921
US

IV. Provider business mailing address

8706 MISSION RD
SAN ANTONIO TX
78214-3140
US

V. Phone/Fax

Practice location:
  • Phone: 210-921-9396
  • Fax:
Mailing address:
  • Phone: 210-924-9265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number110298
License Number StateTX

VIII. Authorized Official

Name: LORA S. BUTLER
Title or Position: PRESIDENT, CEO
Credential:
Phone: 210-334-2437