Provider Demographics
NPI:1407931926
Name:BRENDA'S DEVINE HERITAGE RESIDENTIAL CARE CENTER
Entity Type:Organization
Organization Name:BRENDA'S DEVINE HERITAGE RESIDENTIAL CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:BURFORD
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:210-387-7515
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:
Mailing Address - City:DEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:78016-0224
Mailing Address - Country:US
Mailing Address - Phone:210-387-7515
Mailing Address - Fax:
Practice Address - Street 1:309 BRISCOE AVE
Practice Address - Street 2:
Practice Address - City:DEVINE
Practice Address - State:TX
Practice Address - Zip Code:78016-3003
Practice Address - Country:US
Practice Address - Phone:210-387-7515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
TX1154663104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001001115OtherCCAC