Provider Demographics
NPI:1043758626
Name:MGW SUPPORTIVE HOME LIVING
Entity Type:Organization
Organization Name:MGW SUPPORTIVE HOME LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-490-4444
Mailing Address - Street 1:PO BOX 193
Mailing Address - Street 2:
Mailing Address - City:NEEDVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77461-0193
Mailing Address - Country:US
Mailing Address - Phone:832-490-4444
Mailing Address - Fax:979-793-6134
Practice Address - Street 1:4707 ARBORVINE CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-5700
Practice Address - Country:US
Practice Address - Phone:832-490-4444
Practice Address - Fax:979-793-6134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities