Basic Information
| Provider Information | |||||||||
| NPI: | 1932434198 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARK BEND SCC, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PARK BEND SN HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 N PEARL ST STE 1050 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752017495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142527600 | ||||||||
| FaxNumber: | 2142527704 | ||||||||
| Practice Location | |||||||||
| Address1: | 2122 PARK BEND DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787585352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128369777 | ||||||||
| FaxNumber: | 5128339759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2009 | ||||||||
| LastUpdateDate: | 03/04/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEAL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2142527600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/04/2020 | ||||||||
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 | 001017792 | 05 | TX | MEDICAID |