Basic Information
| Provider Information | |||||||||
| NPI: | 1366726762 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MASON ROUND ROCK OP LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAN GABRIEL REHABILITATION AND CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 COLLEGE PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786651522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123348000 | ||||||||
| FaxNumber: | 5123348005 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 COLLEGE PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786651522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123348000 | ||||||||
| FaxNumber: | 5123348005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2011 | ||||||||
| LastUpdateDate: | 09/27/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5123348000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 133434 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001020004 | 05 | TX | MEDICAID | 105009 | 01 | TX | FACILITY ID | OTHER |