Basic Information
| Provider Information | |||||||||
| NPI: | 1790236198 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOURSQUARE TEXAS 16, LLC | ||||||||
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| OtherOrganizationName: | ASHTON MEDICAL LODGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4311 OAK LAWN AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752192315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723037500 | ||||||||
| FaxNumber: | 9723039700 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 SOUTH LOOP 250 WEST | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326892100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2016 | ||||||||
| LastUpdateDate: | 10/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | SHANE | ||||||||
| AuthorizedOfficialMiddleName: | DELBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 9723037500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.