=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508127325
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MDTJ CAREGIVERS,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2012
-----------------------------------------------------
Last Update Date | 08/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11707 EVESBOROUGH DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77099-1907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-498-7340
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11707 EVESBOROUGH DR,
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-498-7340
-----------------------------------------------------
Fax | 281-809-5982
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. IBIBA MACHARRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-628-7947
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3140N1450X
-----------------------------------------------------
Taxonomy Name | Pediatric Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------