Healthcare Provider Details

I. General information

NPI: 1285140798
Provider Name (Legal Business Name): STONEBRIDGE PLACE OF BRYAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 KENT ST
BRYAN TX
77802-5214
US

IV. Provider business mailing address

1905 N 7TH ST
WEST MONROE LA
71291-4415
US

V. Phone/Fax

Practice location:
  • Phone: 979-776-7521
  • Fax:
Mailing address:
  • Phone: 318-812-2140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DAWNE SMITH
Title or Position: MANAGER
Credential:
Phone: 318-812-2140