MEDICARE: 2ND HOME RESIDENTIAL AND SUPPORT 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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1740131457
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	2ND HOME RESIDENTIAL AND SUPPORT LLC

Provider Business Mailing Address
First Line	:	19126 MOSSY HEDGE LN
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77449-4133
Country	:	US
Telephone Number	:	832-408-0556
Fax Number	:	281-713-5445

Provider Business Practice Location Address
First Line	:	19126 MOSSY HEDGE LN
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77449-4133
Country	:	US
Telephone Number	:	832-408-0556
Fax Number	:	281-713-5445

Authorized Official
Title or Position	:	PROGRAM MANAGER
Name	:	DEANDRA JOHNSON-EGESI
Credential	:	RN
Telephone Number	:	832-785-4089

Provider Enumeration Date	:	02/07/2026
Last Update Date	:	02/07/2026

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