1821212309 NPI number — ADVANCED LIVING TECHNOLOGIES INC

Table of content: (NPI 1821212309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821212309 NPI number — ADVANCED LIVING TECHNOLOGIES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED LIVING TECHNOLOGIES INC
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:
MANOR OAKS NURSING CENTER
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:
1821212309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10415 MORADO CIR
Provider Second Line Business Mailing Address:
SUITE 3 120
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78759-5696
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-345-0700
Provider Business Mailing Address Fax Number:
888-368-3534

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 S FM 487
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKDALE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76567-5047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-446-5893
Provider Business Practice Location Address Fax Number:
512-446-6785
Provider Enumeration Date:
04/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
512-345-0700

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  117722 , 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: 000496303 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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