Basic Information
| Provider Information | |||||||||
| NPI: | 1487641296 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POLK NURSING HOME LIMITED PARTNERSHIP | ||||||||
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| OtherOrganizationName: | TIMBERWOOD NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | RR 2 | ||||||||
| Address2: | HIGHWAY 59 NORTH BYPASS | ||||||||
| City: | LIVINGSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773519802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9363274446 | ||||||||
| FaxNumber: | 9363278435 | ||||||||
| Practice Location | |||||||||
| Address1: | 6633 E HIGHWAY 290 | ||||||||
| Address2: | SUITE # 202 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787231172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124585707 | ||||||||
| FaxNumber: | 5124585751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HIMMEL | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5124585707 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 113278 | TX | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | HH2664 | 01 | TX | BCBS OF TEXAS | OTHER |