Basic Information
Provider Information | |||||||||
NPI: | 1396205852 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DSL TENANT II LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DISCOVERY VILLAGE AT SOUTHLAKE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 27599 RIVERVIEW CENTER BLVD STE 201 | ||||||||
Address2: |   | ||||||||
City: | BONITA SPRINGS | ||||||||
State: | FL | ||||||||
PostalCode: | 341344327 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2399082921 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 201 WATERMERE DR | ||||||||
Address2: |   | ||||||||
City: | SOUTHLAKE | ||||||||
State: | TX | ||||||||
PostalCode: | 760928137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8174821340 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2019 | ||||||||
LastUpdateDate: | 08/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORTON | ||||||||
AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED AGENT | ||||||||
AuthorizedOfficialTelephone: | 2393015311 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.