Healthcare Provider Details

I. General information

NPI: 1780761171
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: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 BURR RD
SAN ANTONIO TX
78209-6217
US

IV. Provider business mailing address

8706 MISSION RD
SAN ANTONIO TX
78214-3140
US

V. Phone/Fax

Practice location:
  • Phone: 201-828-1246
  • Fax:
Mailing address:
  • Phone: 210-924-9265
  • Fax: 210-922-6006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number105610
License Number StateTX

VIII. Authorized Official

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