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General NPI Number Information
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NPI Number | 1235668625
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Entity Type | Organization
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Legal Business Name | RED BEARD LLC
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Dates
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Enumeration Date | 06/08/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 265 COUNTY ROAD 613
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City | DAYTON
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State | TX
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Zip | 77535
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Country | US
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Telephone | 936-258-6803
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Fax |
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Provider Business Mailing Address
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Address Line | 265 COUNTY ROAD 613
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City | DAYTON
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State | TX
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Zip | 77535-4325
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Country | US
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Telephone | 936-258-6803
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | REBECCA JOHNSON
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Credential |
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Telephone | 936-776-0703
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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