Provider Demographics
NPI:1114123015
Name:PROFESSIONAL CARE FACILITY
Entity Type:Organization
Organization Name:PROFESSIONAL CARE FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATONDRA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:ASKEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-877-8557
Mailing Address - Street 1:6327 TEAGUE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75241-4844
Mailing Address - Country:US
Mailing Address - Phone:214-372-3690
Mailing Address - Fax:972-224-5589
Practice Address - Street 1:6327 TEAGUE DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75241-4844
Practice Address - Country:US
Practice Address - Phone:214-372-3690
Practice Address - Fax:972-224-5589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX030258320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities