MEDICARE: EBONY EYES EXCEPTIONAL CARE 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1326700550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EBONY EYES EXCEPTIONAL CARE LLC

Provider Business Mailing Address
First Line	:	3100 GILLESPIE ST APT 402
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77020-5965
Country	:	US
Telephone Number	:	346-800-7135
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 GILLESPIE ST APT 402
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77020-5965
Country	:	US
Telephone Number	:	346-800-7135
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROGRAM MANAGER
Name	:	EBONY NELSON
Credential	:
Telephone Number	:	346-800-7135

Provider Enumeration Date	:	10/05/2021
Last Update Date	:	05/07/2026

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