Healthcare Provider Details

I. General information

NPI: 1295146546
Provider Name (Legal Business Name): CHARLESTON BOERNE OPERATIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 05/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 RYAN ST
BOERNE TX
78006-2046
US

IV. Provider business mailing address

200 RYAN ST
BOERNE TX
78006-2046
US

V. Phone/Fax

Practice location:
  • Phone: 830-249-2594
  • Fax: 830-248-1314
Mailing address:
  • Phone: 830-249-2594
  • Fax: 830-248-1314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number135182
License Number StateTX

VIII. Authorized Official

Name: KENDALL A BROUSSARD
Title or Position: MANAGING MEMBER
Credential:
Phone: 337-439-6600