MEDICARE: EMMANUEL RESIDENTIAL SERVICES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251C00000X	Developmentally Disabled Services Day Training Agency
2	261QA0600X	Adult Day Care Clinic/Center
3	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
4	171W00000X	Contractor
5	310400000X	Assisted Living Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245509504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMMANUEL RESIDENTIAL SERVICES

Provider Business Mailing Address
First Line	:	1328 HERITAGE BLVD STE 5
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75605-1472
Country	:	US
Telephone Number	:	903-260-0412
Fax Number	:

Provider Business Practice Location Address
First Line	:	1328 HERITAGE BLVD STE 5
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75605-1472
Country	:	US
Telephone Number	:	903-260-0412
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM MANAGER
Name	:	MRS. LA TONYA S POLK
Credential	:
Telephone Number	:	903-315-8302

Provider Enumeration Date	:	12/15/2011
Last Update Date	:	04/15/2026

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Directions to “EMMANUEL RESIDENTIAL SERVICES ” Practice Location

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