Healthcare Provider Details

I. General information

NPI: 1700275898
Provider Name (Legal Business Name): LONGHORN VILLAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12501 LONGHORN PKWY
AUSTIN TX
78732-1267
US

IV. Provider business mailing address

12501 LONGHORN PKWY
AUSTIN TX
78732-1267
US

V. Phone/Fax

Practice location:
  • Phone: 512-266-5600
  • Fax: 512-266-5601
Mailing address:
  • Phone: 512-266-5600
  • Fax: 512-266-5601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number137833
License Number StateTX

VIII. Authorized Official

Name: MR. STEPHEN P. BALLANTYNE
Title or Position: CHAIRMAN
Credential:
Phone: 512-266-5600