MEDICARE: DESIRE TO LIVE

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	311500000X	Alzheimer Center (Dementia Center)	132672	TX
2	3104A0625X	Assisted Living Facility (Mental Illness)	132672	TX
3	3104A0630X	Assisted Living Facility (Behavioral Disturbances)	132672	TX
4	310500000X	Mental Illness Intermediate Care Facility	132672	TX
5	311ZA0620X	Adult Care Home Facility	132672	TX
6	315P00000X	Intellectual Disabilities Intermediate Care Facility	132672	TX
7	310400000X	Assisted Living Facility	132672	TX

General Provider Information

NPI Number	:	1407133184
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESIRE TO LIVE

Provider Business Mailing Address
First Line	:	3083 SILVER CEDAR TRL
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77449-6280
Country	:	US
Telephone Number	:	832-512-3863
Fax Number	:	281-331-0453

Provider Business Practice Location Address
First Line	:	2220 COUNTY ROAD 144
Second Line	:
City	:	ALVIN
State	:	TX
Zip	:	77511-7847
Country	:	US
Telephone Number	:	832-512-3863
Fax Number	:	281-331-0453

Authorized Official
Title or Position	:	CEO
Name	:	WANDA FAYE BUTLER
Credential	:	M.ED
Telephone Number	:	832-512-3863

Provider Enumeration Date	:	11/09/2011
Last Update Date	:	11/09/2011

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Directions to “DESIRE TO LIVE ” Practice Location

Language	Start Address	Practice Location

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