Provider Demographics
NPI:1578816799
Name:CHRISTIAN LIFE RESIDENTIAL SERVICES
Entity Type:Organization
Organization Name:CHRISTIAN LIFE RESIDENTIAL SERVICES
Other - Org Name:MARTHA GAIL MILLER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-489-9977
Mailing Address - Street 1:226 E ROYALL BLVD
Mailing Address - Street 2:
Mailing Address - City:MALAKOFF
Mailing Address - State:TX
Mailing Address - Zip Code:75148-9110
Mailing Address - Country:US
Mailing Address - Phone:903-489-9977
Mailing Address - Fax:903-698-2827
Practice Address - Street 1:226 E ROYALL BLVD
Practice Address - Street 2:
Practice Address - City:MALAKOFF
Practice Address - State:TX
Practice Address - Zip Code:75148-9110
Practice Address - Country:US
Practice Address - Phone:903-489-9977
Practice Address - Fax:903-698-2827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1972702298Medicaid