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General NPI Number Information
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NPI Number | 1144422932
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Entity Type | Organization
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Legal Business Name | FAMILY TREE
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Dates
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Enumeration Date | 06/04/2007
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Last Update Date | 03/26/2024
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Provider Practice Location Address
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Address Line | 408 N WASHINGTON AVE
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City | BRYAN
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State | TX
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Zip | 77803-5310
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Country | US
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Telephone | 979-822-6467
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Fax | 979-821-9448
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Provider Business Mailing Address
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Address Line | 1504 TEXAS AVE. P.O. BOX 4588
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City | BRYAN
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State | TX
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Zip | 77805-4588
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Country | US
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Telephone | 979-822-6467
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Fax | 979-821-9448
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | BILL KELLY
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Credential |
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Telephone | 979-822-6467
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 7662
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License Number State | TX
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