Provider Demographics
NPI:1245509504
Name:EMMANUEL RESIDENTIAL SERVICES
Entity type:Organization
Organization Name:EMMANUEL RESIDENTIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LA TONYA
Authorized Official - Middle Name:S
Authorized Official - Last Name:POLK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-315-8302
Mailing Address - Street 1:PO BOX 8664
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75607-8664
Mailing Address - Country:US
Mailing Address - Phone:903-315-8302
Mailing Address - Fax:
Practice Address - Street 1:205 E US HIGHWAY 80
Practice Address - Street 2:
Practice Address - City:WHITE OAK
Practice Address - State:TX
Practice Address - Zip Code:75693-2103
Practice Address - Country:US
Practice Address - Phone:903-315-8302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-15
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1245509504Medicaid