1477879401 NPI number — PHCC-BRODIE RANCH REHABILITATION & HEALTH CARE CENTER, LLC

Table of content: (NPI 1477879401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477879401 NPI number — PHCC-BRODIE RANCH REHABILITATION & HEALTH CARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHCC-BRODIE RANCH REHABILITATION & HEALTH CARE CENTER, LLC
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:
Provider Other Organization Name Type Code:
6
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:
1477879401
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19115 FM 2252
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
GARDEN RIDGE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78266-2577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-545-6320
Provider Business Mailing Address Fax Number:
210-545-2730

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 FRATE BARKER ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78748-3614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-545-6320
Provider Business Practice Location Address Fax Number:
210-545-2730
Provider Enumeration Date:
04/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MEYERS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
210-545-6320

Provider Taxonomy Codes

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




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