Basic Information
| Provider Information | |||||||||
| NPI: | 1003867201 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRCC HOLDINGS LTD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SILVER TREE NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 ROY RICHARD DR | ||||||||
| Address2: | |||||||||
| City: | SCHERTZ | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781541050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105669100 | ||||||||
| FaxNumber: | 2105669102 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 ROY RICHARD DR | ||||||||
| Address2: | |||||||||
| City: | SCHERTZ | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781541050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105669100 | ||||||||
| FaxNumber: | 2105669102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 07/28/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HALLSTED | ||||||||
| AuthorizedOfficialFirstName: | JAKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | LIMITED PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2105669100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 102647 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 159330301 | 01 | TX | MEDICAID TPI | OTHER | 001014283 | 05 | TX | MEDICAID |