Provider Demographics
NPI:1487837316
Name:MILAGRO DISCOVERY HOME AND COMMUNITY HEALTHCARE SERVICE
Entity Type:Organization
Organization Name:MILAGRO DISCOVERY HOME AND COMMUNITY HEALTHCARE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:EVETTE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-815-1385
Mailing Address - Street 1:PO BOX 760595
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-0595
Mailing Address - Country:US
Mailing Address - Phone:210-815-1385
Mailing Address - Fax:
Practice Address - Street 1:6810 BANDERA RD STE 1
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-1468
Practice Address - Country:US
Practice Address - Phone:210-446-4706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
TX143171261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3498107Medicaid