MEDICARE: ENCHANTMENT LIVING HHC 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	:	1568983385
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENCHANTMENT LIVING HHC LLC

Provider Business Mailing Address
First Line	:	5927 IRIS ISLE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78218-3091
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5927 IRIS ISLE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78218-3091
Country	:	US
Telephone Number	:	210-273-8016
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	CAROLYN RANDLE
Credential	:
Telephone Number	:	210-273-8016

Provider Enumeration Date	:	07/01/2017
Last Update Date	:	07/01/2017

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