MEDICARE: SHALOM COKER 24 HOURS SPECIAL NEEDS DAYCARE

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	315P00000X	Intellectual Disabilities Intermediate Care Facility	LVN#221824	TX

General Provider Information

NPI Number	:	1720496409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHALOM COKER 24 HOURS SPECIAL NEEDS DAYCARE

Provider Business Mailing Address
First Line	:	3103 GREGORY LN
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-5742
Country	:	US
Telephone Number	:	972-374-6955
Fax Number	:

Provider Business Practice Location Address
First Line	:	3103 GREGORY LN
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-5742
Country	:	US
Telephone Number	:	972-374-6955
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	SHALOM OSUNDE
Credential	:
Telephone Number	:	972-374-6955

Provider Enumeration Date	:	07/25/2014
Last Update Date	:	07/25/2014

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