Healthcare Provider Details

I. General information

NPI: 1285934232
Provider Name (Legal Business Name): MASON GEORGETOWN OP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 WILLIAMS DR
GEORGETOWN TX
78628-2491
US

IV. Provider business mailing address

4011 WILLIAMS DR
GEORGETOWN TX
78628-2491
US

V. Phone/Fax

Practice location:
  • Phone: 512-868-2700
  • Fax: 512-868-2999
Mailing address:
  • Phone: 512-868-2700
  • Fax: 512-868-2999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number134293
License Number StateTX

VIII. Authorized Official

Name: BRIAN R. THREADGILL
Title or Position: ADMINISTRATOR
Credential:
Phone: 512-868-2700