Healthcare Provider Details

I. General information

NPI: 1245509504
Provider Name (Legal Business Name): EMMANUEL RESIDENTIAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 11/30/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E US HIGHWAY 80
WHITE OAK TX
75693-2103
US

IV. Provider business mailing address

PO BOX 8664
LONGVIEW TX
75607-8664
US

V. Phone/Fax

Practice location:
  • Phone: 903-315-8302
  • Fax:
Mailing address:
  • Phone: 903-315-8302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. LA TONYA S POLK
Title or Position: PROGRAM MANAGER
Credential:
Phone: 903-315-8302