=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003118266
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAY AREA COMMUNITY SUPPORT SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2010
-----------------------------------------------------
Last Update Date | 11/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 ORANGE ST
-----------------------------------------------------
City | LA MARQUE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77568-6241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-893-0424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 762
-----------------------------------------------------
City | LEAGUE CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77574-0762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-893-0424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. LENITA C JACKSON
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 409-354-9701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 789762
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 789762
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number | 789762
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------