MEDICARE: BENNY RAY HOWARD ESTATE

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	125187	TX
2	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1871812123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BENNY RAY HOWARD ESTATE

Provider Business Mailing Address
First Line	:	2107 BRUNSWICK DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78723-2023
Country	:	US
Telephone Number	:	512-928-2498
Fax Number	:	512-928-2473

Provider Business Practice Location Address
First Line	:	2107 BRUNSWICK DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78723-2023
Country	:	US
Telephone Number	:	512-928-2498
Fax Number	:	512-928-2473

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	BRENDA F HOWARD
Credential	:
Telephone Number	:	512-928-2498

Provider Enumeration Date	:	05/26/2010
Last Update Date	:	08/02/2019

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