MEDICARE: LTC OF AUSTIN COUNTY I, LLC

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	313M00000X	Nursing Facility/Intermediate Care Facility	100852	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	100852	OTHER	TX	FACILITY LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508176520
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LTC OF AUSTIN COUNTY I, LLC

Provider Business Mailing Address
First Line	:	1401 EAGLE LAKE RD
Second Line	:
City	:	SEALY
State	:	TX
Zip	:	77474-3109
Country	:	US
Telephone Number	:	979-865-2937
Fax Number	:	979-865-0780

Provider Business Practice Location Address
First Line	:	1401 EAGLE LAKE RD
Second Line	:
City	:	SEALY
State	:	TX
Zip	:	77474-3109
Country	:	US
Telephone Number	:	979-865-2937
Fax Number	:	979-865-0780

Authorized Official
Title or Position	:	MANAGER
Name	:	CELINA C SHARIFF
Credential	:
Telephone Number	:	832-651-3694

Provider Enumeration Date	:	10/08/2010
Last Update Date	:	10/27/2011

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