Provider Demographics
NPI:1104591478
Name:GINA ASSISTED LIVING
Entity type:Organization
Organization Name:GINA ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:E
Authorized Official - Last Name:BESONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-494-0623
Mailing Address - Street 1:28418 ENCHANTED SHORES LN
Mailing Address - Street 2:
Mailing Address - City:FULSHEAR
Mailing Address - State:TX
Mailing Address - Zip Code:77441-1791
Mailing Address - Country:US
Mailing Address - Phone:832-494-0623
Mailing Address - Fax:
Practice Address - Street 1:28418 ENCHANTED SHORES LN
Practice Address - Street 2:
Practice Address - City:FULSHEAR
Practice Address - State:TX
Practice Address - Zip Code:77441-1791
Practice Address - Country:US
Practice Address - Phone:832-494-0623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities