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General NPI Number Information
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NPI Number | 1083851125
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Entity Type | Organization
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Legal Business Name | FAITH ASSISTED LIVING GROUP HOME
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Dates
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Enumeration Date | 01/12/2009
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Last Update Date | 01/12/2009
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Provider Practice Location Address
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Address Line | 5201 WHITEHAVE DR
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City | GARLAND
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State | TX
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Zip | 75043
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Country | US
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Telephone | 817-658-0722
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Fax |
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Provider Business Mailing Address
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Address Line | 5201 WHITEHAVE DR
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City | GARLAND
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State | TX
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Zip | 75043
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Country | US
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Telephone | 817-658-0722
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF ADMINITRATION
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Name | MOLUA I BECKE
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Credential |
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Telephone | 817-658-0722
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 658067
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 343800000X
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Taxonomy Name | Secured Medical Transport (VAN)
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License Number | 24206663
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 3104A0630X
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Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
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License Number | 8067
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License Number State | TX
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