Provider Demographics
NPI:1497026827
Name:STRAWBERRY LANE
Entity Type:Organization
Organization Name:STRAWBERRY LANE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COTA
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-355-1272
Mailing Address - Street 1:417 OAKLAND LN
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77302-1216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:417 OAKLAND LN
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77302-1216
Practice Address - Country:US
Practice Address - Phone:936-355-1272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209506314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility