Basic Information
| Provider Information | |||||||||
| NPI: | 1659644185 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCC PARTNERS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SENIOR CARE HEALTH AND REHABILITATION - BRIDGEPORT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1413 E I 30 | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | GARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750434784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723037500 | ||||||||
| FaxNumber: | 9723039700 | ||||||||
| Practice Location | |||||||||
| Address1: | 2108 15TH ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764262055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406835023 | ||||||||
| FaxNumber: | 9406833184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2012 | ||||||||
| LastUpdateDate: | 11/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | SHANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 9723037500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SCC HEALTHCARE GROUP, LTD. | ||||||||
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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 | 001017174 | 05 | TX | MEDICAID |