MEDICARE: PERIWINKLE HOUSE

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	112128	TX

General Provider Information

NPI Number	:	1356563183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERIWINKLE HOUSE

Provider Business Mailing Address
First Line	:	1638 PERIWINKLE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77038-2911
Country	:	US
Telephone Number	:	281-379-4833
Fax Number	:	281-379-6068

Provider Business Practice Location Address
First Line	:	1638 PERIWINKLE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77038-2911
Country	:	US
Telephone Number	:	281-448-9005
Fax Number	:	281-379-6068

Authorized Official
Title or Position	:	CEO
Name	:	MR. JOHN M LUGAY SR.
Credential	:
Telephone Number	:	281-379-4833

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	08/04/2008

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Directions to “PERIWINKLE HOUSE ” Practice Location

Language	Start Address	Practice Location

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