=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932815867
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABLE ASSISTED LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2023
-----------------------------------------------------
Last Update Date | 01/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 581 SHERWOOD LN
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75840-1917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-848-4632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 TOM LANDRY HWY # 224774
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75260-9990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-848-4632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. DEETRA ROCHELLE JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-498-4024
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------