Provider Demographics
NPI:1407005929
Name:CONLY'S ASSISTED LIVING HOME
Entity Type:Organization
Organization Name:CONLY'S ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:IVORY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PETE
Authorized Official - Suffix:
Authorized Official - Credentials:BUSINESS MANAGMENT
Authorized Official - Phone:281-706-3717
Mailing Address - Street 1:PO BOX 73723
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77273-3723
Mailing Address - Country:US
Mailing Address - Phone:281-209-3710
Mailing Address - Fax:713-695-5554
Practice Address - Street 1:6819 MORROW ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77091-2321
Practice Address - Country:US
Practice Address - Phone:713-697-1792
Practice Address - Fax:713-695-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101623261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health