Basic Information
| Provider Information | |||||||||
| NPI: | 1295114296 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLEAR BROOK SCC LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SCC AT CLEAR BROOK CROSSING REHABILITATION AND HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10800 FLORA MAE MEADOWS RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770895974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323282350 | ||||||||
| FaxNumber: | 8323282351 | ||||||||
| Practice Location | |||||||||
| Address1: | 10800 FLORA MAE MEADOWS RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770895974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323282350 | ||||||||
| FaxNumber: | 8323282351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2015 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRICE | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9494775800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/17/2020 | ||||||||
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 | 001026999 | 05 | TX | MEDICAID | 5645-103595 | 01 | TX | VENDOR ID/FACILITY ID | OTHER |