Healthcare Provider Details

I. General information

NPI: 1922143700
Provider Name (Legal Business Name): EAST TEXAS COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 ROOSEVELT DR
SILSBEE TX
77656-3408
US

IV. Provider business mailing address

PO BOX 2185
SILSBEE TX
77656-2185
US

V. Phone/Fax

Practice location:
  • Phone: 409-385-3723
  • Fax: 409-385-9304
Mailing address:
  • Phone: 409-385-2626
  • Fax: 409-385-9307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number7554
License Number StateTX

VIII. Authorized Official

Name: MR. D. MICHAEL JOHNSON
Title or Position: PRESIDENT
Credential:
Phone: 409-385-2626