Basic Information
| Provider Information | |||||||||
| NPI: | 1821084138 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIVINGSTON HEALTH CARE CENTER LTD. CO. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE BRADFORD AT BROOKSIDE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2537 GOLDEN BEAR DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750062377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149544114 | ||||||||
| FaxNumber: | 2148713057 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 WEST PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773518151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9363274341 | ||||||||
| FaxNumber: | 9363276277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 12/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | UNDERHILL | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 2149544114 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | TX | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 314000000X | 114558 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 022634201 | 05 | TX | MEDICAID | 155314101 | 05 | TX | MEDICAID | HH068S | 01 | TX | BLUE CROSS | OTHER | 000465804 | 05 | TX | MEDICAID |