=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043623457
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASSURED CARE LIVING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2014
-----------------------------------------------------
Last Update Date | 06/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2603 1/2 HARRINGTON ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77026-7409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-410-6206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2603 1/2 HARRINGTON ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77026-7409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-410-6206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ONWER
-----------------------------------------------------
Name | YARIC O'KEITH BERNARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-410-6206
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3104A0630X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------