Provider Demographics
NPI:1538532429
Name:MISSION ROAD DEVELOPMENTAL CENTER
Entity type:Organization
Organization Name:MISSION ROAD DEVELOPMENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LORA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-334-2437
Mailing Address - Street 1:8706 MISSION RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78214-3140
Mailing Address - Country:US
Mailing Address - Phone:210-924-9265
Mailing Address - Fax:210-922-6006
Practice Address - Street 1:8706 MISSION RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78214-3140
Practice Address - Country:US
Practice Address - Phone:210-924-9265
Practice Address - Fax:210-922-6006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123357310400000X
TX123265310400000X
TX117405310400000X
TX117406310400000X
TX016040251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility