=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386982700
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARLA'S COMMUNITY LIVING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2013
-----------------------------------------------------
Last Update Date | 01/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1408 TEXAS AVE
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79401-4036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-771-0602
-----------------------------------------------------
Fax | 806-771-0658
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1408 TEXAS AVE
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79401-4036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-771-0602
-----------------------------------------------------
Fax | 806-771-0658
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MARY E WATSON
-----------------------------------------------------
Credential | M.ED.
-----------------------------------------------------
Telephone | 806-771-0602
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------