Organization
DISTINCTIVE DIFFERENCES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CICELY GIBSON (OWNER)
(281) 743-1583
Entity
Organization
Contact information
Practice address
3514 LYDIA ST, HOUSTON, TX 77021-5914
(281) 743-1583
Mailing address
PO BOX 330467, HOUSTON, TX 77233-0467
Taxonomy
Speciality
Code
Description
License number
State
310400000X
Assisted Living Facility
—
—
3104A0625X
Assisted Living Facility (Mental Illness)
Primary
—
—
3104A0630X
Assisted Living Facility (Behavioral Disturbances)
—
—
Other
Enumeration date
10/15/2012
Last updated
10/15/2012
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