Provider Demographics
NPI:1114171881
Name:DAVENPORT RESIDENTIAL CARE HOME
Entity Type:Organization
Organization Name:DAVENPORT RESIDENTIAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-344-2260
Mailing Address - Street 1:1649 LCR 310
Mailing Address - Street 2:
Mailing Address - City:MART
Mailing Address - State:TX
Mailing Address - Zip Code:76664-5207
Mailing Address - Country:US
Mailing Address - Phone:254-344-2260
Mailing Address - Fax:245-344-2472
Practice Address - Street 1:1649 LCR 310
Practice Address - Street 2:
Practice Address - City:MART
Practice Address - State:TX
Practice Address - Zip Code:76664-5207
Practice Address - Country:US
Practice Address - Phone:254-344-2260
Practice Address - Fax:245-344-2472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000442310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001016443Medicaid