Basic Information
| Provider Information | |||||||||
| NPI: | 1649253303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEARS BRAZOS RETIREMENT CORPORATION | ||||||||
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| OtherOrganizationName: | WESLEY WOODS ALZHEIMER'S CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 VILLAGE DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796068231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256915519 | ||||||||
| FaxNumber: | 3256984582 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 WOODGATE DR | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767128600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2546665454 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2005 | ||||||||
| LastUpdateDate: | 04/26/2010 | ||||||||
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| AuthorizedOfficialLastName: | CROSSWHTE | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/ASST. CFO | ||||||||
| AuthorizedOfficialTelephone: | 3256915519 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | 113492 | TX | Y | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |
ID Information
| ID | Type | State | Issuer | Description | 67-6211 | 01 | TX | MEDICARE SNF | OTHER | 001012296 | 05 | TX | MEDICAID |