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General NPI Number Information
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NPI Number | 1689902389
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Entity Type | Organization
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Legal Business Name | AMISTAD RESIDENTAL FACILITY
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Dates
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Enumeration Date | 11/18/2009
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Last Update Date | 11/18/2009
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Provider Practice Location Address
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Address Line | 309 W NORWOOD CT
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City | SAN ANTONIO
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State | TX
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Zip | 78212-2222
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Country | US
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Telephone | 210-832-9578
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Fax | 210-832-9578
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Provider Business Mailing Address
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Address Line | 309 W NORWOOD CT
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City | SAN ANTONIO
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State | TX
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Zip | 78212-2222
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Country | US
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Telephone | 210-832-9578
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Fax | 210-832-9578
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Authorized Official
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Title or Position | PROVIDER
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Name | MS. NANCY MURRAH
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Credential |
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Telephone | 210-725-6293
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 127885
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License Number State | TX
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