Basic Information
| Provider Information | |||||||||
| NPI: | 1770807216 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | S-H OPCO SPICEWOOD SPRINGS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROOKDALE SPICEWOOD SPRINGS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6737 W WASHINGTON ST | ||||||||
| Address2: | SUITE 2300 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532145647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149185332 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4401 SPICEWOOD SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787598682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124188822 | ||||||||
| FaxNumber: | 5124188825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2010 | ||||||||
| LastUpdateDate: | 12/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | OHLENDORF | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4149185000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BROOKDALE SENIOR LIVING INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 129734 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 67-5533 | 01 | MEDICARE PTAN | OTHER |