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General NPI Number Information
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NPI Number | 1417015322
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Entity Type | Organization
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Legal Business Name | INDEPENDENT LIVING OF TEXARKANA, LLC
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Dates
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Enumeration Date | 12/04/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3120 SMITH ST
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City | TEXARKANA
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State | TX
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Zip | 75501-4083
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Country | US
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Telephone | 903-831-3911
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Fax | 903-831-4195
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Provider Business Mailing Address
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Address Line | 3120 SMITH ST
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City | TEXARKANA
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State | TX
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Zip | 75501-4083
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Country | US
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Telephone | 903-831-3911
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Fax | 903-831-4195
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Authorized Official
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Title or Position | MEMBER
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Name | FAGIE PINTER
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Credential |
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Telephone | 903-831-3911
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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 | 118529
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License Number State | TX
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