MEDICARE: EAST TEXAS COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility	7482	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7482	OTHER	TX	VENDOR

General Provider Information

NPI Number	:	1003951922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST TEXAS COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED, INC.

Provider Business Mailing Address
First Line	:	PO BOX 2185
Second Line	:
City	:	SILSBEE
State	:	TX
Zip	:	77656-2185
Country	:	US
Telephone Number	:	409-385-2626
Fax Number	:	409-385-9304

Provider Business Practice Location Address
First Line	:	2204 NORTH 24TH ST
Second Line	:
City	:	ORANGE
State	:	TX
Zip	:	77630-3115
Country	:	US
Telephone Number	:	409-886-5950
Fax Number	:	409-886-5587

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. D MICHAEL JOHNSON
Credential	:
Telephone Number	:	409-385-2626

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	08/22/2020

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