Healthcare Provider Details

I. General information

NPI: 1053547463
Provider Name (Legal Business Name): MASON DESSAU OP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11020 DESSAU ROAD
AUSTIN TX
78754-2053
US

IV. Provider business mailing address

11020 DESSAU RD
AUSTIN TX
78754-2053
US

V. Phone/Fax

Practice location:
  • Phone: 512-873-2244
  • Fax: 512-873-2249
Mailing address:
  • Phone: 512-873-2244
  • Fax: 512-873-2249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number135482
License Number StateTX

VIII. Authorized Official

Name: RUSSELL A. CLARK
Title or Position: ADMINISTRATOR
Credential:
Phone: 512-873-2244