Provider Demographics
NPI:1457759045
Name:KYLIE'S ADULT DAYCARE SERVICES
Entity Type:Organization
Organization Name:KYLIE'S ADULT DAYCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NGOZI
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-742-9407
Mailing Address - Street 1:4593 MOUNTAIN LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-2903
Mailing Address - Country:US
Mailing Address - Phone:972-805-6674
Mailing Address - Fax:972-698-0488
Practice Address - Street 1:3939 US HIGHWAY 80 E
Practice Address - Street 2:305
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-3359
Practice Address - Country:US
Practice Address - Phone:972-805-6674
Practice Address - Fax:972-698-0844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-12
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287445501Medicaid