MEDICARE: ANDRE HANCOCK SR. FAMILY GROUP HOME

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	:	1396061685
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDRE HANCOCK SR. FAMILY GROUP HOME

Provider Business Mailing Address
First Line	:	1012 FARM MARKET ROAD 2377
Second Line	:
City	:	RED OAK
State	:	TX
Zip	:	75154
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1012 FARM MARKET ROAD 2377
Second Line	:
City	:	RED OAK
State	:	TX
Zip	:	75154
Country	:	US
Telephone Number	:	214-460-6930
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	IRMA CROSBY
Credential	:
Telephone Number	:	214-460-6930

Provider Enumeration Date	:	04/13/2010
Last Update Date	:	04/13/2010

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