Provider Demographics
NPI:1477698488
Name:EAST TEXAS COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED, INC.
Entity Type:Organization
Organization Name:EAST TEXAS COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED, INC.
Other - Org Name:WOODLEA COMMUNITY HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:D
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-385-2626
Mailing Address - Street 1:PO BOX 2185
Mailing Address - Street 2:
Mailing Address - City:SILSBEE
Mailing Address - State:TX
Mailing Address - Zip Code:77656-2185
Mailing Address - Country:US
Mailing Address - Phone:409-385-2626
Mailing Address - Fax:409-385-9304
Practice Address - Street 1:101 OGLESBEE RD
Practice Address - Street 2:
Practice Address - City:SILSBEE
Practice Address - State:TX
Practice Address - Zip Code:77656-5925
Practice Address - Country:US
Practice Address - Phone:409-385-5807
Practice Address - Fax:409-385-9304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7413315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7413OtherVENDOR