MEDICARE: ST. GILES LIVING CENTERS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility

General Provider Information

NPI Number	:	1104427509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. GILES LIVING CENTERS, INC.

Provider Business Mailing Address
First Line	:	4800 OVERTON PLZ STE 440
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4435
Country	:	US
Telephone Number	:	800-299-5161
Fax Number	:

Provider Business Practice Location Address
First Line	:	2812 SHAFFER LN
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75702-1653
Country	:	US
Telephone Number	:	800-299-5161
Fax Number	:	817-447-3033

Authorized Official
Title or Position	:	OPERATIONS BUSINESS MANAGER
Name	:	ANNA TODD
Credential	:
Telephone Number	:	800-299-5161

Provider Enumeration Date	:	11/03/2020
Last Update Date	:	11/03/2020

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