Provider Demographics
NPI:1861811218
Name:21STCENTURY HOMECARE SERVICES
Entity type:Organization
Organization Name:21STCENTURY HOMECARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:832-656-4391
Mailing Address - Street 1:440 BENMAR DR
Mailing Address - Street 2:3053
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-3165
Mailing Address - Country:US
Mailing Address - Phone:832-326-8291
Mailing Address - Fax:
Practice Address - Street 1:6710 LINDALE MANOR CT
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-8931
Practice Address - Country:US
Practice Address - Phone:832-656-4391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103T00000XMedicaid