Provider Demographics
NPI:1255820379
Name:FRESH OUTPOURING OUTREACH CENTER
Entity type:Organization
Organization Name:FRESH OUTPOURING OUTREACH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:OMORUYI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-775-8463
Mailing Address - Street 1:186 SANDPEBBLE DR
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-3225
Mailing Address - Country:US
Mailing Address - Phone:832-775-8463
Mailing Address - Fax:
Practice Address - Street 1:186 SANDPEBBLE DR
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77381-3225
Practice Address - Country:US
Practice Address - Phone:832-775-8463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities