=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588041941
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGGS FOSTER CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2015
-----------------------------------------------------
Last Update Date | 05/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 E BUCHANAN AVE
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75602-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-753-4517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 E BUCHANAN AVE
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75602-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-753-4517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARY HIGGS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-753-4517
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 118569
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------