=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952909616
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSLYNS SENIOR LIFESTYLE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2020
-----------------------------------------------------
Last Update Date | 10/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21040 HIGHLAND KNOLLS DR STE 200-437
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-1570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-239-9676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21040 HIGHLAND KNOLLS DR STE 200-437
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-1570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-239-9676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ADRIANE ANDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 346-239-9676
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 373H00000X
-----------------------------------------------------
Taxonomy Name | Day Training/Habilitation Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 376G00000X
-----------------------------------------------------
Taxonomy Name | Nursing Home Administrator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------