Basic Information
| Provider Information | |||||||||
| NPI: | 1366457723 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDER HEALTHCARE SERVICES OF LULING, LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OAKCREEK NURSING AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3420 EXECUTIVE CENTER DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787311624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123439070 | ||||||||
| FaxNumber: | 5123431060 | ||||||||
| Practice Location | |||||||||
| Address1: | 1105 N MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786481604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308755606 | ||||||||
| FaxNumber: | 8308755857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MORGAN | ||||||||
| AuthorizedOfficialFirstName: | TED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5123439070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 117854 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1014325 | 05 | TX | MEDICAID |