MEDICARE: ESTEEMED SENIOR LIVING

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	3104A0625X	Assisted Living Facility (Mental Illness)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0	OTHER		N/A

General Provider Information

NPI Number	:	1841946787
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ESTEEMED SENIOR LIVING

Provider Business Mailing Address
First Line	:	3027 LILY LN
Second Line	:
City	:	HEATH
State	:	TX
Zip	:	75126-0617
Country	:	US
Telephone Number	:	254-229-9275
Fax Number	:

Provider Business Practice Location Address
First Line	:	2101 DIANE DR
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75074-3545
Country	:	US
Telephone Number	:	469-970-0277
Fax Number	:

Authorized Official
Title or Position	:	C.E.O.
Name	:	MR. BENNIE GRIFFIN
Credential	:	LVN
Telephone Number	:	254-229-9275

Provider Enumeration Date	:	03/01/2022
Last Update Date	:	11/21/2022

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Directions to “ESTEEMED SENIOR LIVING ” Practice Location

Language	Start Address	Practice Location

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