MEDICARE: RUSTIC TRAILS 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		TX

General Provider Information

NPI Number	:	1932368776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSTIC TRAILS LLC

Provider Business Mailing Address
First Line	:	200 W HIGHWAY 6
Second Line	:	SUITE 509
City	:	WACO
State	:	TX
Zip	:	76712-7923
Country	:	US
Telephone Number	:	254-399-6788
Fax Number	:	254-399-6766

Provider Business Practice Location Address
First Line	:	200 W HIGHWAY 6
Second Line	:	SUITE 509
City	:	WACO
State	:	TX
Zip	:	76712-7923
Country	:	US
Telephone Number	:	254-399-6788
Fax Number	:	254-399-6766

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MICHAEL BUMPASS
Credential	:
Telephone Number	:	254-399-6788

Provider Enumeration Date	:	06/06/2008
Last Update Date	:	06/06/2008

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Directions to “RUSTIC TRAILS LLC ” Practice Location

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