Healthcare Provider Details

I. General information

NPI: 1003180977
Provider Name (Legal Business Name): GLOW OF HAPPINESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2012
Last Update Date: 10/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 RIVER RIDGE DR
WACO TX
76705-1758
US

IV. Provider business mailing address

99 RIVER RIDGE DR
WACO TX
76705-1758
US

V. Phone/Fax

Practice location:
  • Phone: 254-644-0128
  • Fax:
Mailing address:
  • Phone: 254-644-0128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number001021396
License Number StateTX

VIII. Authorized Official

Name: DESEREA M MORGAN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 254-644-0128