=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215333703
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRISTOL ENTERPRISES BAY AREA INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2014
-----------------------------------------------------
Last Update Date | 02/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17043 EL CAMINO REAL SUITE 107
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77058-2653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-861-2000
-----------------------------------------------------
Fax | 409-861-2002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2390 EASTEX FWY SUITE 100
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77703-4638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-861-2000
-----------------------------------------------------
Fax | 409-861-2002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/OWNER
-----------------------------------------------------
Name | STEPHANIE ALLEN
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 409-861-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------