MEDICARE: MS. BETTY'S PLACE, LLC

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1144768581
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MS. BETTY'S PLACE, LLC

Provider Business Mailing Address
First Line	:	816 GREEN COVE LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75232-1638
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	816 GREEN COVE LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75232-1638
Country	:	US
Telephone Number	:	315-664-5335
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RONALD HYDER
Credential	:
Telephone Number	:	315-664-5335

Provider Enumeration Date	:	02/06/2017
Last Update Date	:	02/06/2017

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