Basic Information
Provider Information | |||||||||
NPI: | 1104063387 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WINDSOR NURSING CENTER PARTNERS OF LLANO, LTD. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LLANO NURSING AND REHABILITATION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 101 W GOODWIN AVE | ||||||||
Address2: | STE 600 | ||||||||
City: | VICTORIA | ||||||||
State: | TX | ||||||||
PostalCode: | 779016502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3615760694 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 800 W HAYNIE ST | ||||||||
Address2: |   | ||||||||
City: | LLANO | ||||||||
State: | TX | ||||||||
PostalCode: | 786431905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3252474194 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/09/2009 | ||||||||
LastUpdateDate: | 01/09/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LACERDA | ||||||||
AuthorizedOfficialFirstName: | HEBER | ||||||||
AuthorizedOfficialMiddleName: | S. | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3615760694 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   | TX | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 4545 | 05 | TX |   | MEDICAID |