=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073913034
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOVE & CARE RESIDENTIAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2014
-----------------------------------------------------
Last Update Date | 09/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4325 BLUEBONNET CT
-----------------------------------------------------
City | ABILENE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79606-2660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-518-6052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4325 BLUEBONNET CT
-----------------------------------------------------
City | ABILENE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79606-2660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-518-6052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ PROGRAM MANAGER
-----------------------------------------------------
Name | TRACEY MINTHREE CUNNINGHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 325-518-6052
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------