Basic Information
| Provider Information | |||||||||
| NPI: | 1205572641 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEADOW LAKE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15601 DALLAS PKWY | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013353 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 16044 COUNTY ROAD 165 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757037302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035265599 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2022 | ||||||||
| LastUpdateDate: | 05/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | HARSHFIELD | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 5152885805 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.