Basic Information
| Provider Information | |||||||||
| NPI: | 1255327029 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LA VIDA SERENA NURSING AND REHABILITATION LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762014137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403874388 | ||||||||
| FaxNumber: | 9403802410 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 KINGS WAY | ||||||||
| Address2: | |||||||||
| City: | DEL RIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788402029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8307740698 | ||||||||
| FaxNumber: | 8307740959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 07/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | RICH | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9403874388 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1109889 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 155895901 | 01 | TX | TMHP(DME CROSS OVER) | OTHER | 001004412 | 05 | TX | MEDICAID | 155895902 | 01 | TX | TMHP(CROSS OVER) | OTHER |