=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164871554
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEVEN STAR HORSE & FAMILY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2016
-----------------------------------------------------
Last Update Date | 06/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4667 S. FM 1258
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-355-4773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 50655
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79159-0655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-355-4773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | RACHAEL WADE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-355-4773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------