Basic Information
| Provider Information | |||||||||
| NPI: | 1013914191 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDER HEALTHCARE SERVICES OF LULING, LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OAKCREEK NURSING & REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1105 N MAGNOLIA AVE | ||||||||
| Address2: | P. O. BOX 1066 | ||||||||
| City: | LULING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786481604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308755606 | ||||||||
| FaxNumber: | 8308755857 | ||||||||
| Practice Location | |||||||||
| Address1: | 1105 N MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786481604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308755606 | ||||||||
| FaxNumber: | 8308755857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORGAN | ||||||||
| AuthorizedOfficialFirstName: | TED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AGENT | ||||||||
| AuthorizedOfficialTelephone: | 5123439070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 005045 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.