Basic Information
| Provider Information | |||||||||
| NPI: | 1851857304 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOURSQUARE TEXAS 16 LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4311 OAK LAWN AVE STE 400 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752192363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723037500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 750 HIGHWAY 352 | ||||||||
| Address2: | |||||||||
| City: | MESQUITE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727888900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2019 | ||||||||
| LastUpdateDate: | 02/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | SHANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| 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.