Basic Information
| Provider Information | |||||||||
| NPI: | 1538119367 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLC - PATRIOT HEIGHTS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROOKDALE PATRIOT HEIGHTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 WESTWOOD PL | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152212250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5000 FAWN MDWS | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782401539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106966005 | ||||||||
| FaxNumber: | 2106417881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 02/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | OHLENDORF | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3129773700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BROOKDALE SENIOR LIVING INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 114148 | TX | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 314000000X | 114144 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001013188 | 05 | TX | MEDICAID |