Provider Demographics
NPI:1679793319
Name:SHIRLEY ANDERSON
Entity Type:Organization
Organization Name:SHIRLEY ANDERSON
Other - Org Name:NEW LIFE OUTREACH BOARDING HOMES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:FRANCES
Authorized Official - Middle Name:
Authorized Official - Last Name:MEADER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-758-9353
Mailing Address - Street 1:PO BOX 12478
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75607-2478
Mailing Address - Country:US
Mailing Address - Phone:903-758-9353
Mailing Address - Fax:903-758-9153
Practice Address - Street 1:2016 S HIGH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75602-3248
Practice Address - Country:US
Practice Address - Phone:903-758-9353
Practice Address - Fax:903-758-9153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
TX1186583104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000150200Medicaid