Basic Information
| Provider Information | |||||||||
| NPI: | 1720404981 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH LIMESTONE HOSPITAL DISTRICT | ||||||||
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| OtherOrganizationName: | SAN GABRIEL REHABILITATION AND CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 COLLEGE PARK | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786651522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123348000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4100 COLLEGE PARK | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786651522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123348000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2014 | ||||||||
| LastUpdateDate: | 03/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | PRICE | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2547293281 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001025869 | 05 | TX | MEDICAID |