Basic Information
| Provider Information | |||||||||
| NPI: | 1144422932 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY TREE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1504 TEXAS AVE. | ||||||||
| Address2: | P.O. BOX 4588 | ||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778054588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9798226467 | ||||||||
| FaxNumber: | 9798219448 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 N WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778035310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9798226467 | ||||||||
| FaxNumber: | 9798219448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 08/12/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9798226467 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 7662 | TX | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 000766201 | 05 | TX | MEDICAID |