Provider Demographics
NPI:1043396013
Name:BRENDA'S DEVINE HERITAGE RESIDENTIAL, INC
Entity type:Organization
Organization Name:BRENDA'S DEVINE HERITAGE RESIDENTIAL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:BURFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-387-7515
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:
Mailing Address - City:DEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:78016-0224
Mailing Address - Country:US
Mailing Address - Phone:210-387-7515
Mailing Address - Fax:
Practice Address - Street 1:309 BRISCOE AVE
Practice Address - Street 2:
Practice Address - City:DEVINE
Practice Address - State:TX
Practice Address - Zip Code:78016
Practice Address - Country:US
Practice Address - Phone:830-665-2000
Practice Address - Fax:830-663-2832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
TX1146523104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001001579OtherCBA