Provider Demographics
NPI:1619508025
Name:THE SPECIAL NEEDS ACTIVITY CENTER
Entity Type:Organization
Organization Name:THE SPECIAL NEEDS ACTIVITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:L
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-216-5269
Mailing Address - Street 1:3911 S LANCASTER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-5682
Mailing Address - Country:US
Mailing Address - Phone:469-216-5269
Mailing Address - Fax:
Practice Address - Street 1:3911 S LANCASTER RD STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-5682
Practice Address - Country:US
Practice Address - Phone:469-216-5269
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No305S00000XManaged Care OrganizationsPoint of Service
No347E00000XTransportation ServicesTransportation Broker