| NPI | 1437434206 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | EDMOND S MAXON Ed 817-494-6875 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: TX 22799) |
| Additional Taxonomies | 320600000X Residential Treatment Facility, Intellectual and/or Developmental Disabilities (Licence: TX 22799) |
| Enumeration Date | 2011-10-12 |
| Last Update Date | 2011-10-12 |