MEDICARE: KITTY FORREST ELLIS

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	:	1669618179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KITTY FORREST ELLIS

Provider Business Mailing Address
First Line	:	2331 CANYON CREEK DR
Second Line	:
City	:	TEMPLE
State	:	TX
Zip	:	76502-3112
Country	:	US
Telephone Number	:	254-771-2358
Fax Number	:

Provider Business Practice Location Address
First Line	:	2331 CANYON CREEK DR
Second Line	:
City	:	TEMPLE
State	:	TX
Zip	:	76502-3112
Country	:	US
Telephone Number	:	254-771-2358
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. KITTY FORREST ELLIS
Credential	:
Telephone Number	:	254-771-2358

Provider Enumeration Date	:	01/05/2009
Last Update Date	:	01/05/2009

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Directions to “KITTY FORREST ELLIS ” Practice Location

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