Basic Information
| Provider Information | |||||||||
| NPI: | 1851849897 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOURSQUARE TEXAS 16 LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHERIDAN MEDICAL LODGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4311 OAK LAWN | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723037500 | ||||||||
| FaxNumber: | 9723039700 | ||||||||
| Practice Location | |||||||||
| Address1: | 1119 S. RED RIVER EXPRESSWAY | ||||||||
| Address2: | |||||||||
| City: | BURKBURNETT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405699500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2016 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | SHANE | ||||||||
| AuthorizedOfficialMiddleName: | DELBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 9723037500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
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 | 001028346 | 05 | TX | MEDICAID |