Provider Demographics
NPI:1578182838
Name:QUEEN OF SAFETY SUPPLY CO., LLC
Entity Type:Organization
Organization Name:QUEEN OF SAFETY SUPPLY CO., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RACHAEL
Authorized Official - Middle Name:SHANNEL
Authorized Official - Last Name:COSTLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-788-7048
Mailing Address - Street 1:PO BOX 720034
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77272-0034
Mailing Address - Country:US
Mailing Address - Phone:225-788-7048
Mailing Address - Fax:
Practice Address - Street 1:9500 COUNTY ROAD 190
Practice Address - Street 2:
Practice Address - City:MANVEL
Practice Address - State:TX
Practice Address - Zip Code:77578-5078
Practice Address - Country:US
Practice Address - Phone:225-788-7048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)