Basic Information
| Provider Information | |||||||||
| NPI: | 1942685383 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHADY SHORES OF BERTRAM LLC | ||||||||
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| OtherOrganizationName: | BERTRAM NURSING AND REHAB CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 EAGLE DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762016898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9402281414 | ||||||||
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| Practice Location | |||||||||
| Address1: | 540 E. HIGHWAY 29 | ||||||||
| Address2: | |||||||||
| City: | BERTRAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786054473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123552116 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2015 | ||||||||
| LastUpdateDate: | 06/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2144221622 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.