Basic Information
| Provider Information | |||||||||
| NPI: | 1811224264 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARLYLE HEALTH CARE CENTER LTD CO | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE CARLYLE AT STONEBRIDGE PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2537 GOLDEN BEAR DR | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750062377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149544114 | ||||||||
| FaxNumber: | 2148713057 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 STONEBRIDGE LN | ||||||||
| Address2: | |||||||||
| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760920306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149544114 | ||||||||
| FaxNumber: | 2148713057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2009 | ||||||||
| LastUpdateDate: | 10/25/2010 | ||||||||
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| AuthorizedOfficialLastName: | UNDERHILL | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2149544114 | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 001018031 | 05 | TX | MEDICAID |