=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013307206
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEMORY & WELLNESS SENIOR CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2015
-----------------------------------------------------
Last Update Date | 07/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8802 BROADWAY
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78217-5678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-488-8526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8802 BROADWAY ST
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78217-6318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-488-8526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | PIUS OLUKOYA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-488-8526
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------