Basic Information
| Provider Information | |||||||||
| NPI: | 1487028585 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHADY SHORES OF POTEET LLC | ||||||||
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| OtherOrganizationName: | POTEET MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 EAGLE DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762016898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9402281414 | ||||||||
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| Practice Location | |||||||||
| Address1: | 329 SCHOOL DR | ||||||||
| Address2: | |||||||||
| City: | POTEET | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780654307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8307423525 | ||||||||
| FaxNumber: | 8307428710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2015 | ||||||||
| LastUpdateDate: | 06/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2144221622 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.