MEDICARE: KEITH MARTEL TAYLOR

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	:	1982807897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEITH MARTEL TAYLOR

Provider Business Mailing Address
First Line	:	440 BENMAR DR
Second Line	:	#1225
City	:	HOUSTON
State	:	TX
Zip	:	77060-3165
Country	:	US
Telephone Number	:	281-847-1883
Fax Number	:	281-847-1845

Provider Business Practice Location Address
First Line	:	440 BENMAR DR STE 1225
Second Line	:	1225
City	:	HOUSTON
State	:	TX
Zip	:	77060-3165
Country	:	US
Telephone Number	:	281-847-1883
Fax Number	:	281-847-1845

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	MS. SHERYL PHELPS HOSEA
Credential	:
Telephone Number	:	281-847-1883

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	07/16/2007

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