MEDICARE: TOMODACHI SERVICE PROVIDER CORPORATION

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1831336304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOMODACHI SERVICE PROVIDER CORPORATION

Provider Business Mailing Address
First Line	:	5918 SCHROEDER RD APT 23
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77021-3506
Country	:	US
Telephone Number	:	713-385-0006
Fax Number	:

Provider Business Practice Location Address
First Line	:	5918 SCHROEDER RD APT 23
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77021-3506
Country	:	US
Telephone Number	:	713-385-0006
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. BRODRICK ROBERSON
Credential	:
Telephone Number	:	713-385-0006

Provider Enumeration Date	:	01/20/2009
Last Update Date	:	01/20/2009

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Directions to “TOMODACHI SERVICE PROVIDER CORPORATION ” Practice Location

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