Provider Demographics
NPI:1124195524
Name:INDIVIDUAL CARE OF TEXAS, INC
Entity Type:Organization
Organization Name:INDIVIDUAL CARE OF TEXAS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-771-2350
Mailing Address - Street 1:P O BOX 1419
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-1419
Mailing Address - Country:US
Mailing Address - Phone:972-771-2350
Mailing Address - Fax:972-771-4860
Practice Address - Street 1:1655 P.R. 2530
Practice Address - Street 2:
Practice Address - City:QUINLAN
Practice Address - State:TX
Practice Address - Zip Code:75474-1810
Practice Address - Country:US
Practice Address - Phone:903-356-4526
Practice Address - Fax:903-356-4544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115880310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility