Basic Information
| Provider Information | |||||||||
| NPI: | 1689951543 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCK CREEK HEALTH AND REHABILITATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762014137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403874388 | ||||||||
| FaxNumber: | 9403802410 | ||||||||
| Practice Location | |||||||||
| Address1: | 1414 COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | SULPHUR SPRINGS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754823431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034390107 | ||||||||
| FaxNumber: | 9034390147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2011 | ||||||||
| LastUpdateDate: | 07/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9403874388 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 295239201 | 01 | TX | MEDICAID CO B CROSS-OVER | OTHER | 001020121 | 05 | TX | MEDICAID |