Provider Demographics
NPI:1386053593
Name:MAXINES PERSONAL CARE HOME
Entity type:Organization
Organization Name:MAXINES PERSONAL CARE HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:D AUTROL
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1936-377-2115
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:OAKHURST
Mailing Address - State:TX
Mailing Address - Zip Code:77359-0155
Mailing Address - Country:US
Mailing Address - Phone:936-377-2115
Mailing Address - Fax:
Practice Address - Street 1:#1910 STATE HWY 190 EAST
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:TX
Practice Address - Zip Code:77359-0155
Practice Address - Country:US
Practice Address - Phone:936-377-2115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX310400000X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility