Provider Demographics
NPI:1730317322
Name:MAVERICK ADULT DAY CARE L.L.C.
Entity Type:Organization
Organization Name:MAVERICK ADULT DAY CARE L.L.C.
Other - Org Name:FORT DUNCAN HOME HEALTH AND HOSPICE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:MR
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTANA
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BNS
Authorized Official - Phone:830-757-0966
Mailing Address - Street 1:3147 MEGAN ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-5891
Mailing Address - Country:US
Mailing Address - Phone:830-757-0966
Mailing Address - Fax:830-757-0976
Practice Address - Street 1:3147 MEGAN ST
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-5891
Practice Address - Country:US
Practice Address - Phone:830-757-0966
Practice Address - Fax:830-757-0976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX009852251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX192509104Medicaid
TX192509103Medicaid