Healthcare Provider Details

I. General information

NPI: 1720469513
Provider Name (Legal Business Name): COPPERAS AL OPERATOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 COUNTRY CLUB DR
CALDWELL TX
77836-2328
US

IV. Provider business mailing address

111 CLIFTON AVE
LAKEWOOD NJ
08701-3342
US

V. Phone/Fax

Practice location:
  • Phone: 979-567-6400
  • Fax: 979-567-6434
Mailing address:
  • Phone: 214-396-3462
  • Fax: 214-396-3482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: JOE NEUMAN
Title or Position: CEO
Credential:
Phone: 214-396-3462