Basic Information
| Provider Information | |||||||||
| NPI: | 1699972539 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DALLAS HOME FOR JEWISH AGED, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE LEGACY AT PRESTON HOLLOW | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6101 OHIO DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750242720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724686171 | ||||||||
| FaxNumber: | 9724686172 | ||||||||
| Practice Location | |||||||||
| Address1: | 11409 N CENTRAL EXPY | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752436678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143635100 | ||||||||
| FaxNumber: | 2413635133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 09/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | BARNES | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9724686171 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 112773 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 165795901 | 01 | TX | PART B CO-INSURANCE | OTHER | 001012220 | 05 | TX | MEDICAID |