Basic Information
| Provider Information | |||||||||
| NPI: | 1811984313 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLANCO VILLA NURSING AND REHABILITATION LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 419 S ELM ST | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762016085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403874388 | ||||||||
| FaxNumber: | 9403802410 | ||||||||
| Practice Location | |||||||||
| Address1: | 8020 BLANCO RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782163702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103444553 | ||||||||
| FaxNumber: | 2103663728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 01/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | FLAGG | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9403874388 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 118137 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1635088 01 | 01 | TX | TMHP CROSS OVER | OTHER | 001004850 | 05 | TX | MEDICAID |