Provider Demographics
NPI:1073634432
Name:EDUCARE COMMUNITY LIVING CORPORATION - TEXAS
Entity Type:Organization
Organization Name:EDUCARE COMMUNITY LIVING CORPORATION - TEXAS
Other - Org Name:EC BEAU SAN DIEGO
Other - Org Type:Other Name
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHOBREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-630-7249
Mailing Address - Street 1:805 N WHITTINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-7101
Mailing Address - Country:US
Mailing Address - Phone:502-394-2100
Mailing Address - Fax:
Practice Address - Street 1:7585 SAN DIEGO ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77708-2305
Practice Address - Country:US
Practice Address - Phone:409-892-1784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000396701Medicaid