Basic Information
| Provider Information | |||||||||
| NPI: | 1609206077 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROADMOOR CONTINUING CARE CENTER LTD. CO. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE BROADMOOR AT CREEKSIDE PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2537 GOLDEN BEAR DR | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750062377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149544114 | ||||||||
| FaxNumber: | 2148800053 | ||||||||
| Practice Location | |||||||||
| Address1: | 5665 CREEKSIDE FOREST DR | ||||||||
| Address2: | |||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773894969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812558180 | ||||||||
| FaxNumber: | 2812558190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2013 | ||||||||
| LastUpdateDate: | 04/30/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | LEGAL ASSISTANT/CLAIMS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2149544114 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001025592 | 05 | TX | MEDICAID |