=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700810637
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVING HOPE HEALING WATERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 PINE ST
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75501-5100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-791-8388
-----------------------------------------------------
Fax | 903-791-8385
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 HAZEL ST
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75501-5229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-791-8388
-----------------------------------------------------
Fax | 903-791-8385
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | DAVID KIMBRO STEPHENS
-----------------------------------------------------
Credential | J.D.
-----------------------------------------------------
Telephone | 903-791-8388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------