Provider Demographics
NPI:1003205618
Name:NEW HAVEN ASSISTED LIVING AND MEMORY CARE
Entity type:Organization
Organization Name:NEW HAVEN ASSISTED LIVING AND MEMORY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-975-1609
Mailing Address - Street 1:2300 FM 3009
Mailing Address - Street 2:
Mailing Address - City:SCHERTZ
Mailing Address - State:TX
Mailing Address - Zip Code:78154-2785
Mailing Address - Country:US
Mailing Address - Phone:210-319-4965
Mailing Address - Fax:210-319-4947
Practice Address - Street 1:2300 FM 3009
Practice Address - Street 2:
Practice Address - City:SCHERTZ
Practice Address - State:TX
Practice Address - Zip Code:78154-2785
Practice Address - Country:US
Practice Address - Phone:210-319-4965
Practice Address - Fax:210-319-4947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105481311500000X
TX105480310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)