Provider Demographics
NPI:1952434896
Name:CORNELL CORRECTIONS OF TEXAS
Entity Type:Organization
Organization Name:CORNELL CORRECTIONS OF TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MARTENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-568-8600
Mailing Address - Street 1:620 E AFTON OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1236
Mailing Address - Country:US
Mailing Address - Phone:210-568-8600
Mailing Address - Fax:210-490-9430
Practice Address - Street 1:620 E AFTON OAKS BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1236
Practice Address - Country:US
Practice Address - Phone:210-568-8600
Practice Address - Fax:210-490-9430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX109325402Medicaid