=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922418219
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NGU HOME, NEW LIFE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2014
-----------------------------------------------------
Last Update Date | 05/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4166 SURREYDON DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77014-2152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-584-9760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 683168
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77268-3168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NYSSA NGU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-584-9760
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------