Basic Information
| Provider Information | |||||||||
| NPI: | 1336537398 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MYSTIC PARK SCC LLC | ||||||||
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| OtherOrganizationName: | MYSTIC PARK NURSING & REHAB CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 N PEARL ST STE 1050 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752017495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142527600 | ||||||||
| FaxNumber: | 2142527704 | ||||||||
| Practice Location | |||||||||
| Address1: | 8503 MYSTIC PARK | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782542544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102560906 | ||||||||
| FaxNumber: | 2102560925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2014 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEAL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2142527600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
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 | 001026539 | 05 | TX | MEDICAID | 5447 101669 | 01 | TX | VENDORID/FACILITY ID | OTHER |