Provider Demographics
NPI:1336310556
Name:LIBERTY ISLAND PERSONAL CARE HOME
Entity Type:Organization
Organization Name:LIBERTY ISLAND PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-530-0000
Mailing Address - Street 1:9009 BOONE RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77099-2033
Mailing Address - Country:US
Mailing Address - Phone:281-530-0000
Mailing Address - Fax:281-530-3735
Practice Address - Street 1:9009 BOONE RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77099-2033
Practice Address - Country:US
Practice Address - Phone:281-530-0000
Practice Address - Fax:281-530-3735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-15
Last Update Date:2008-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00080900320800000X
TX00098700320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00080900OtherPERSONAL CARE HOME
TX00098700OtherPERSONAL CARE HOME