Provider Demographics
NPI:1457787079
Name:SR SAM
Entity Type:Organization
Organization Name:SR SAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:K
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-677-2248
Mailing Address - Street 1:502 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:TX
Mailing Address - Zip Code:77571-3310
Mailing Address - Country:US
Mailing Address - Phone:832-677-2248
Mailing Address - Fax:
Practice Address - Street 1:502 N 5TH ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:TX
Practice Address - Zip Code:77571-3310
Practice Address - Country:US
Practice Address - Phone:832-677-2248
Practice Address - Fax:281-471-1263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX311Z00000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home