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General NPI Number Information
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NPI Number | 1497232805
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Entity Type | Organization
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Legal Business Name | HEATHERS OLD SKOOL VILLAGE
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Dates
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Enumeration Date | 07/27/2018
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Last Update Date | 07/27/2018
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Provider Practice Location Address
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Address Line | 6018 GRAHAM ST
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City | LAKE WORTH
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State | TX
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Zip | 76135-3304
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Country | US
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Telephone | 817-236-8275
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Fax | 817-236-8275
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Provider Business Mailing Address
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Address Line | 6018 GRAHAM ST
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City | LAKE WORTH
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State | TX
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Zip | 76135-3304
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Country | US
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Telephone | 817-236-8275
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Fax | 817-236-8275
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. MARGARET GRACE JOHNSON
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Credential |
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Telephone | 817-236-8275
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State | TX
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