=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588025530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A PRECIOUS PLACE FOR ME, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2016
-----------------------------------------------------
Last Update Date | 03/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3501 VIEWCREST DR
-----------------------------------------------------
City | KILLEEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76549-4202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-310-6583
-----------------------------------------------------
Fax | 254-415-7218
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5400 E RIVERWOOD CT
-----------------------------------------------------
City | KILLEEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76542-5376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-310-6583
-----------------------------------------------------
Fax | 254-415-7218
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-310-6583
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------