1508176520 NPI number — LTC OF AUSTIN COUNTY I, LLC

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 1508176520 NPI number — LTC OF AUSTIN COUNTY I, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LTC OF AUSTIN COUNTY I, 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:
1508176520
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 EAGLE LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEALY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77474-3109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-865-2937
Provider Business Mailing Address Fax Number:
979-865-0780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 EAGLE LAKE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEALY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77474-3109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-865-2937
Provider Business Practice Location Address Fax Number:
979-865-0780
Provider Enumeration Date:
10/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SHARIFF
Authorized Official First Name:
CELINA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
832-651-3694

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  100852 , 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: 100852 . This is a "FACILITY LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5424 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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