MEDICARE: NICK KNOX JR.

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	:	1811171663
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICK KNOX JR.

Provider Business Mailing Address
First Line	:	7034 BALLINGER RIDGE LN
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77469-4058
Country	:	US
Telephone Number	:	832-272-4799
Fax Number	:

Provider Business Practice Location Address
First Line	:	7034 BALLINGER RIDGE LN
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77469-4058
Country	:	US
Telephone Number	:	832-272-4799
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. NICK KNOX JR.
Credential	:	N/A
Telephone Number	:	832-272-4799

Provider Enumeration Date	:	12/27/2007
Last Update Date	:	12/27/2007

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