Healthcare Provider Details

I. General information

NPI: 1235746272
Provider Name (Legal Business Name): EMMANUEL LIVING AND ACTIVITY CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
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:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TONY POLK
Title or Position: MEMBER
Credential:
Phone: 903-315-8302