Basic Information
| Provider Information | |||||||||
| NPI: | 1922309962 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANSFIELD SNF LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ISLE AT WATERCREST - MANSFIELD, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5307 E MOCKINGBIRD LN | ||||||||
| Address2: | SUITE 1010 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752065109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143702600 | ||||||||
| FaxNumber: | 2143702699 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E. DEBBIE LANE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174533900 | ||||||||
| FaxNumber: | 8174533909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2010 | ||||||||
| LastUpdateDate: | 02/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | SPAULDING | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | WILLARD | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2143702600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.