Healthcare Provider Details

I. General information

NPI: 1700875705
Provider Name (Legal Business Name): BRENTWOOD HEALTHCARE, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 S BUCKNER BLVD BLDG 2
DALLAS TX
75227-5451
US

IV. Provider business mailing address

600 E WHALEY ST
LONGVIEW TX
75601-6525
US

V. Phone/Fax

Practice location:
  • Phone: 214-388-0609
  • Fax: 214-388-2643
Mailing address:
  • Phone: 903-757-5360
  • Fax: 903-236-7036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number110323
License Number StateTX

VIII. Authorized Official

Name: DICK STEBBINS
Title or Position: PRESIDENT OF GENERAL PARTNER
Credential: CPA
Phone: 903-757-5360