1770752172 NPI number — SOUTH LIMESTONE HOSPITAL DISTRICT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770752172 NPI number — SOUTH LIMESTONE HOSPITAL DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH LIMESTONE HOSPITAL DISTRICT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PROVIDENCE PARK REHABILITATION AND SKILLED NURSING
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770752172
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 WATERS RIDGE DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75057-6056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-899-4126
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5505 NEW COPELAND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703-3955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-939-2443
Provider Business Practice Location Address Fax Number:
903-939-2479
Provider Enumeration Date:
02/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PRICE
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
N.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
254-729-3281

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  124617 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001021325 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 197010501 . This is a "MCD CO B" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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