Provider Demographics
NPI:1083838585
Name:LAND MANOR, INC.
Entity Type:Organization
Organization Name:LAND MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALITY MANAGEMENT DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KAHCLAMAT
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC
Authorized Official - Phone:409-838-3946
Mailing Address - Street 1:PO BOX 7250
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77726-7250
Mailing Address - Country:US
Mailing Address - Phone:409-838-3946
Mailing Address - Fax:409-838-4298
Practice Address - Street 1:355 N 18TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-2229
Practice Address - Country:US
Practice Address - Phone:409-838-3946
Practice Address - Fax:409-838-4298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX124-124H261QR0405X
TX124-F324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX065464202Medicaid