Provider Demographics
NPI:1063447001
Name:MILESTONE GERIATRIC DAY CARE, INC
Entity Type:Organization
Organization Name:MILESTONE GERIATRIC DAY CARE, INC
Other - Org Name:MILESTONE BEHAVIOR HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:LUEEL
Authorized Official - Last Name:IRVING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-429-2290
Mailing Address - Street 1:2516 OAKLAND BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-3203
Mailing Address - Country:US
Mailing Address - Phone:817-429-2290
Mailing Address - Fax:814-492-9098
Practice Address - Street 1:2516 OAKLAND BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-3201
Practice Address - Country:US
Practice Address - Phone:817-429-2290
Practice Address - Fax:814-492-9098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153822502Medicaid
TX00121UMedicare PIN