Provider Demographics
NPI:1083851125
Name:FAITH ASSISTED LIVING GROUP HOME
Entity Type:Organization
Organization Name:FAITH ASSISTED LIVING GROUP HOME
Other - Org Name:FAITH ASSISTED LIVING GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF ADMINITRATION
Authorized Official - Prefix:
Authorized Official - First Name:MOLUA
Authorized Official - Middle Name:I
Authorized Official - Last Name:BECKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-658-0722
Mailing Address - Street 1:5201 WHITEHAVE DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043
Mailing Address - Country:US
Mailing Address - Phone:817-658-0722
Mailing Address - Fax:
Practice Address - Street 1:5201 WHITEHAVE DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043
Practice Address - Country:US
Practice Address - Phone:817-658-0722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80673104A0630X
TX658067320900000X
TX24206663343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No343800000XTransportation ServicesSecured Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8067OtherTRANSPOTATION
TX8067OtherTRANSPOTATION