Healthcare Provider Details

I. General information

NPI: 1750680872
Provider Name (Legal Business Name): CEDAR PARK SNF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 S. LAKELINE BLVD.
CEDAR PARK TX
78613-4563
US

IV. Provider business mailing address

5307 E MOCKINGBIRD LN SUITE 1010
DALLAS TX
75206-5109
US

V. Phone/Fax

Practice location:
  • Phone: 512-219-0200
  • Fax: 512-219-0466
Mailing address:
  • Phone: 214-370-2600
  • Fax: 214-370-2699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number133153
License Number StateTX

VIII. Authorized Official

Name: CRAIG SPAULDING
Title or Position: MANAGER
Credential:
Phone: 214-370-6200