Organization
FAMILY TREE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BILL KELLY (EXECUTIVE DIRECTOR)
(979) 822-6467
Entity
Organization
Contact information
Practice address
408 N WASHINGTON AVE, BRYAN, TX 77803-5310
(979) 822-6467
(979) 821-9448
Mailing address
1504 TEXAS AVE., P.O. BOX 4588, BRYAN, TX 77805-4588
(979) 822-6467
(979) 821-9448
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
7662
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000766201
—
TX
Enumeration date
06/04/2007
Last updated
03/26/2024
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