Provider Demographics
NPI:1346327756
Name:MISSION ROAD DEVELOPMENTAL CENTER
Entity Type:Organization
Organization Name:MISSION ROAD DEVELOPMENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LORA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-334-2460
Mailing Address - Street 1:8706 MISSION RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78214-3140
Mailing Address - Country:US
Mailing Address - Phone:210-924-9265
Mailing Address - Fax:
Practice Address - Street 1:7618 MOCKINGBIRD LN
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2624
Practice Address - Country:US
Practice Address - Phone:210-349-8125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104897315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities