Basic Information
| Provider Information | |||||||||
| NPI: | 1578515201 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SENIOR LIVING PROPERTIES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COUNTRY INN HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1389 | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760991389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174107300 | ||||||||
| FaxNumber: | 8178107411 | ||||||||
| Practice Location | |||||||||
| Address1: | 1085 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | VAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757902949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039638646 | ||||||||
| FaxNumber: | 9039635031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 07/24/2007 | ||||||||
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| AuthorizedOfficialLastName: | KEYS | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8174107300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 116017 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004299 | 01 | TX | FACILITY ID NO. | OTHER |