Provider Demographics
NPI:1174296602
Name:O SHINE RESIDENTIAL HOME, INC
Entity Type:Organization
Organization Name:O SHINE RESIDENTIAL HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLINTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-903-7600
Mailing Address - Street 1:1903 TRAILRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-4734
Mailing Address - Country:US
Mailing Address - Phone:469-233-6741
Mailing Address - Fax:214-594-9266
Practice Address - Street 1:1903 TRAILRIDGE DR
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-4734
Practice Address - Country:US
Practice Address - Phone:469-233-6741
Practice Address - Fax:214-594-9266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home