Provider Demographics
NPI:1063657450
Name:4 CORNERS RESIDENTIAL CARE, LLC
Entity Type:Organization
Organization Name:4 CORNERS RESIDENTIAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RODERIC
Authorized Official - Middle Name:C
Authorized Official - Last Name:HORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-333-6947
Mailing Address - Street 1:408 W 17TH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1242
Mailing Address - Country:US
Mailing Address - Phone:313-333-6947
Mailing Address - Fax:
Practice Address - Street 1:408 W 17TH ST
Practice Address - Street 2:STE 101
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1242
Practice Address - Country:US
Practice Address - Phone:313-333-6947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities