Provider Demographics
NPI:1689902389
Name:AMISTAD RESIDENTAL FACILITY
Entity Type:Organization
Organization Name:AMISTAD RESIDENTAL FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:MURRAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-725-6293
Mailing Address - Street 1:309 W NORWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2222
Mailing Address - Country:US
Mailing Address - Phone:210-832-9578
Mailing Address - Fax:210-832-9578
Practice Address - Street 1:309 W NORWOOD CT
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2222
Practice Address - Country:US
Practice Address - Phone:210-832-9578
Practice Address - Fax:210-832-9578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX127885302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization