=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972886570
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEXAS INDEPENDENCE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2011
-----------------------------------------------------
Last Update Date | 09/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3653 TIMBERGLEN RD APT 735
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75287-3574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-625-0037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18950 LINA ST APT 828
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75287-2449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | MARKETA JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-625-0037
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------