Provider Demographics
NPI:1407853823
Name:JOHNSON CUSTODIAL HOME, INC.
Entity Type:Organization
Organization Name:JOHNSON CUSTODIAL HOME, INC.
Other - Org Name:MAGGIE JOHNSON NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:KILLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-654-3042
Mailing Address - Street 1:3801 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-3030
Mailing Address - Country:US
Mailing Address - Phone:817-654-3042
Mailing Address - Fax:817-446-3666
Practice Address - Street 1:3406 E 17TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78721-1106
Practice Address - Country:US
Practice Address - Phone:512-926-4760
Practice Address - Fax:512-928-9565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111923313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4694Medicaid