Provider Demographics
NPI:1093899445
Name:CLASSIC GROUP H OME
Entity Type:Organization
Organization Name:CLASSIC GROUP H OME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-452-4661
Mailing Address - Street 1:1454 SOMERCOTES LN
Mailing Address - Street 2:
Mailing Address - City:CHANNELVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:77530-2258
Mailing Address - Country:US
Mailing Address - Phone:281-452-4661
Mailing Address - Fax:281-452-4639
Practice Address - Street 1:1454 SOMERCOTES LN
Practice Address - Street 2:
Practice Address - City:CHANNELVIEW
Practice Address - State:TX
Practice Address - Zip Code:77530-2258
Practice Address - Country:US
Practice Address - Phone:281-452-4661
Practice Address - Fax:281-452-4639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115384320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000756001OtherPROVIDER NUMBER