Provider Demographics
NPI:1790834323
Name:ANNADALE MANOR
Entity Type:Organization
Organization Name:ANNADALE MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-866-9186
Mailing Address - Street 1:10702 COUNTY ROAD 1300
Mailing Address - Street 2:
Mailing Address - City:WOLFFORTH
Mailing Address - State:TX
Mailing Address - Zip Code:79382-7006
Mailing Address - Country:US
Mailing Address - Phone:806-866-9186
Mailing Address - Fax:
Practice Address - Street 1:10702 COUNTY ROAD 1300
Practice Address - Street 2:
Practice Address - City:WOLFFORTH
Practice Address - State:TX
Practice Address - Zip Code:79382-7006
Practice Address - Country:US
Practice Address - Phone:806-866-9186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116184320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities