=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386809309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOSSTOD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2008
-----------------------------------------------------
Last Update Date | 07/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5411 LYNDHURST DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77033-2911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-773-1842
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3110 EBBTIDE DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77045-4508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-434-5007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | SAMUEL DOTSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-434-5007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------