=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538936257
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LILLYWEST HOMES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2023
-----------------------------------------------------
Last Update Date | 12/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4935 ALAINA DR
-----------------------------------------------------
City | ROSHARON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77583-0440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-840-9456
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4935 ALAINA DR
-----------------------------------------------------
City | ROSHARON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77583-0440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | BOMA OLADE
-----------------------------------------------------
Credential | BSN, RN
-----------------------------------------------------
Telephone | 404-441-8752
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0630X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------