Provider Demographics
NPI:1649417031
Name:INTRUST COMMUNITY SERVICES
Entity Type:Organization
Organization Name:INTRUST COMMUNITY SERVICES
Other - Org Name:ICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TOMMIE
Authorized Official - Middle Name:NELL
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-333-4038
Mailing Address - Street 1:PO BOX 6691
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-0691
Mailing Address - Country:US
Mailing Address - Phone:817-333-4038
Mailing Address - Fax:
Practice Address - Street 1:1521 SUNNY GLEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76134-4853
Practice Address - Country:US
Practice Address - Phone:817-333-4038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities