=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922374073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCE ADAPTIVE GROWTH AND DEVELOPMENT CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2012
-----------------------------------------------------
Last Update Date | 03/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13000 VASSAR DR
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75035-2234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-226-8759
-----------------------------------------------------
Fax | 817-466-8756
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13000 VASSAR DR
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75035-2234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-226-8759
-----------------------------------------------------
Fax | 817-466-8756
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | FRANCIS DEKU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-226-8759
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 014342
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------