Provider Demographics
NPI:1104038264
Name:OUTREACH ASSISTED LIVING FACILITY 2
Entity Type:Organization
Organization Name:OUTREACH ASSISTED LIVING FACILITY 2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FAIR
Authorized Official - Middle Name:VIVARD
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:LBSW
Authorized Official - Phone:713-459-1753
Mailing Address - Street 1:5010 RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77033-3541
Mailing Address - Country:US
Mailing Address - Phone:713-731-0645
Mailing Address - Fax:713-998-5323
Practice Address - Street 1:5010 RIDGEWAY DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77033-3541
Practice Address - Country:US
Practice Address - Phone:713-459-1753
Practice Address - Fax:713-988-5323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117656 VENDOR 100958310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10026531OtherLTC PROVIDER