Provider Demographics
NPI:1386061034
Name:IMMACULATE LIVING CARE, LLC
Entity type:Organization
Organization Name:IMMACULATE LIVING CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:COCO
Authorized Official - Last Name:EMBOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-549-2954
Mailing Address - Street 1:12401 OVERBROOK LN
Mailing Address - Street 2:#61D
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-5859
Mailing Address - Country:US
Mailing Address - Phone:361-549-2954
Mailing Address - Fax:
Practice Address - Street 1:12401 OVERBROOK LN
Practice Address - Street 2:#61D
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-5859
Practice Address - Country:US
Practice Address - Phone:361-549-2954
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness