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General NPI Number Information
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NPI Number | 1477698488
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Entity Type | Organization
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Legal Business Name | EAST TEXAS COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED, INC.
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 101 OGLESBEE RD
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City | SILSBEE
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State | TX
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Zip | 77656-5925
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Country | US
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Telephone | 409-385-5807
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Fax | 409-385-9304
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Provider Business Mailing Address
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Address Line | PO BOX 2185
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City | SILSBEE
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State | TX
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Zip | 77656-2185
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Country | US
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Telephone | 409-385-2626
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Fax | 409-385-9304
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. D MICHAEL JOHNSON
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Credential |
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Telephone | 409-385-2626
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 7413
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License Number State | TX
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