Basic Information
Provider Information
NPI: 1083088959
EntityType: 2
ReplacementNPI:  
OrganizationName: RIO ONE AT TARRANT COUNTY, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: THE LODGE AT BEAR CREEK
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 8820 HORIZON BLVD NE
Address2:  
City: ALBUQUERQUE
State: NM
PostalCode: 871131689
CountryCode: US
TelephoneNumber: 5053690079
FaxNumber:  
Practice Location
Address1: 3729 IRA E WOODS AVE
Address2:  
City: GRAPEVINE
State: TX
PostalCode: 760514213
CountryCode: US
TelephoneNumber: 8178098000
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/16/2015
LastUpdateDate: 08/22/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: WHITAKER
AuthorizedOfficialFirstName: KELLEY
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CHIEF OPERATIONS OFFICER
AuthorizedOfficialTelephone: 5053690079
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MRS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
314000000X  Y Nursing & Custodial Care FacilitiesSkilled Nursing Facility 

ID Information
IDTypeStateIssuerDescription
00102738405TX MEDICAID
80216092601TXSTATE LICENSEOTHER


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