MEDICARE: AVICENNACARE 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	:	1396535928
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVICENNACARE LLC

Provider Business Mailing Address
First Line	:	5007 HICKORY DEER LN
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77406-2953
Country	:	US
Telephone Number	:	832-766-7990
Fax Number	:

Provider Business Practice Location Address
First Line	:	5007 HICKORY DEER LN
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77406-2953
Country	:	US
Telephone Number	:	832-766-7990
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM MANAGER
Name	:	ENIOLA ADERANTI GISANRIN
Credential	:
Telephone Number	:	832-766-7990

Provider Enumeration Date	:	05/07/2025
Last Update Date	:	05/07/2025

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