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General NPI Number Information
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NPI Number | 1407853823
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Entity Type | Organization
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Legal Business Name | JOHNSON CUSTODIAL HOME, INC.
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Dates
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Enumeration Date | 06/30/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3406 E 17TH ST
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City | AUSTIN
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State | TX
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Zip | 78721-1106
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Country | US
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Telephone | 512-926-4760
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Fax | 512-928-9565
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Provider Business Mailing Address
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Address Line | 3801 WOODSIDE DR
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City | ARLINGTON
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State | TX
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Zip | 76016-3030
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Country | US
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Telephone | 817-654-3042
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Fax | 817-446-3666
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Authorized Official
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Title or Position | PRESIDENT
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Name | CHERYL L KILLIAN
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Credential |
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Telephone | 817-654-3042
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | 111923
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License Number State | TX
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