MEDICARE: AMAZING LIFE 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
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1508146242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMAZING LIFE CARE, LLC

Provider Business Mailing Address
First Line	:	159 EVANSTON ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77015-1613
Country	:	US
Telephone Number	:	903-917-1115
Fax Number	:

Provider Business Practice Location Address
First Line	:	159 EVANSTON ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77015-1613
Country	:	US
Telephone Number	:	903-917-1115
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM MANAGER/PART-OWNER
Name	:	MR. TRISTAN JOSEPH HOGAN
Credential	:
Telephone Number	:	903-917-1115

Provider Enumeration Date	:	08/25/2011
Last Update Date	:	08/25/2011

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Directions to “AMAZING LIFE CARE, LLC ” Practice Location

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