Basic Information
| Provider Information | |||||||||
| NPI: | 1568799914 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MASON COPPELL OP LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SANDY LAKE REHABILITATION AND CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1410 E SANDY LAKE RD | ||||||||
| Address2: | |||||||||
| City: | COPPELL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750193119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723044444 | ||||||||
| FaxNumber: | 9724626605 | ||||||||
| Practice Location | |||||||||
| Address1: | 1410 E SANDY LAKE RD | ||||||||
| Address2: | |||||||||
| City: | COPPELL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750193119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723044444 | ||||||||
| FaxNumber: | 9724626605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2009 | ||||||||
| LastUpdateDate: | 08/02/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HODGES | ||||||||
| AuthorizedOfficialFirstName: | MARILYN | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9723044444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 131895 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001017901 | 05 | TX | MEDICAID | 104250 | 01 | TX | FACILITY ID | OTHER |