=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356531644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHLAKE EDUCATIONAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2007
-----------------------------------------------------
Last Update Date | 08/01/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 649 CIRCLE VIEW SOUTH
-----------------------------------------------------
City | HURST
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76054-3316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-481-5368
-----------------------------------------------------
Fax | 817-251-0318
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2695 LONESOME DOVE RD
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-3223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-481-5368
-----------------------------------------------------
Fax | 817-251-0318
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMIN/ASSISTANT QMRP
-----------------------------------------------------
Name | MICHELLE DEANNE NEAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-481-5368
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number | 1013303
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------