Basic Information
| Provider Information | |||||||||
| NPI: | 1912332180 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORONADO CONTINUING CARE CENTER LTD CO | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CORONADO AT STONE OAK | ||||||||
| 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: | 19638 STONE OAK PKWY | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782583279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149544114 | ||||||||
| FaxNumber: | 2148713057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2013 | ||||||||
| LastUpdateDate: | 06/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | UNDERHILL | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2149544114 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 138286 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001025524 | 05 | TX | MEDICAID |