Provider Demographics
NPI:1790146942
Name:VILLAGE LIFE CENTER TEXAS
Entity Type:Organization
Organization Name:VILLAGE LIFE CENTER TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARR-BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:919-723-8799
Mailing Address - Street 1:9660 FALLS OF NEUSE ROAD
Mailing Address - Street 2:SUITE 138, #273
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615
Mailing Address - Country:US
Mailing Address - Phone:919-723-8799
Mailing Address - Fax:866-825-9703
Practice Address - Street 1:2101 CRAWFORD ST STE 208
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-8941
Practice Address - Country:US
Practice Address - Phone:713-739-9725
Practice Address - Fax:866-242-3803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0829Medicaid