1225159254 NPI number — EDUCARE COMMUNITY LIVING CORPORATION - TEXAS

Table of content: DR. MIRAVONE DOROUGH D.C, N.D (NPI 1477836450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225159254 NPI number — EDUCARE COMMUNITY LIVING CORPORATION - TEXAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDUCARE COMMUNITY LIVING CORPORATION - TEXAS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EC ANTO TIMBER MEADOW
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225159254
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 N WHITTINGTON PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40222-7101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-394-2100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5401 TIMBER MEADOW ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78250-4203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-680-1818
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WHOBREY
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER ENROLLMENT
Authorized Official Telephone Number:
502-630-7249

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000369601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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