MEDICARE: LORSAM RESIDENTIAL HOMES 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	3104A0625X	Assisted Living Facility (Mental Illness)
2	3104A0630X	Assisted Living Facility (Behavioral Disturbances)

General Provider Information

NPI Number	:	1205145893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LORSAM RESIDENTIAL HOMES INC

Provider Business Mailing Address
First Line	:	8108 MODESTO DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76001-8545
Country	:	US
Telephone Number	:	913-207-9255
Fax Number	:

Provider Business Practice Location Address
First Line	:	8108 MODESTO DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76001-8545
Country	:	US
Telephone Number	:	913-207-9255
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TANGYI FOCHO FOGWE
Credential	:
Telephone Number	:	913-207-9255

Provider Enumeration Date	:	09/29/2010
Last Update Date	:	10/02/2010

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Directions to “LORSAM RESIDENTIAL HOMES INC ” Practice Location

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