Provider Demographics
NPI:1699164954
Name:NEW HAVEN ASSISTED LIVING & MEMORY CARE
Entity type:Organization
Organization Name:NEW HAVEN ASSISTED LIVING & MEMORY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-975-1609
Mailing Address - Street 1:107 CREEKSIDE TRL
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-6261
Mailing Address - Country:US
Mailing Address - Phone:512-400-0683
Mailing Address - Fax:512-400-0684
Practice Address - Street 1:107 CREEKSIDE TRL
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6261
Practice Address - Country:US
Practice Address - Phone:512-400-0683
Practice Address - Fax:512-400-0684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX140434310400000X
TX140429/103276311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)