Provider Demographics
NPI:1568509701
Name:PRESTIGE LIVING CENTER INC.
Entity Type:Organization
Organization Name:PRESTIGE LIVING CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:E
Authorized Official - Last Name:OBOMESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-274-8636
Mailing Address - Street 1:6206 SANFORD RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77096-5729
Mailing Address - Country:US
Mailing Address - Phone:832-274-8636
Mailing Address - Fax:713-772-0701
Practice Address - Street 1:6206 SANFORD RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096-5729
Practice Address - Country:US
Practice Address - Phone:832-274-8636
Practice Address - Fax:713-772-0701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008656251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001013249Medicaid