Basic Information
| Provider Information | |||||||||
| NPI: | 1427345347 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UPTOWN FS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HILLSIDE MEDICAL LODGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4311 OAK LAWN AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752192315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723037500 | ||||||||
| FaxNumber: | 9723039700 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S HIGHWAY 36 BYP N | ||||||||
| Address2: | |||||||||
| City: | GATESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765282764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548658275 | ||||||||
| FaxNumber: | 2548656344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2011 | ||||||||
| LastUpdateDate: | 12/05/2017 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | SHANE | ||||||||
| AuthorizedOfficialMiddleName: | DELBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 9723037515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 5091 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001004431 | 05 | TX | MEDICAID |