Healthcare Provider Details

I. General information

NPI: 1508953399
Provider Name (Legal Business Name): LEGEND HEALTHCARE GLADEWATER, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 FM 2685
GLADEWATER TX
75647
US

IV. Provider business mailing address

1390 E BITTERS RD
SAN ANTONIO TX
78216-2914
US

V. Phone/Fax

Practice location:
  • Phone: 903-845-2175
  • Fax: 903-844-2435
Mailing address:
  • Phone: 210-564-0100
  • Fax: 210-564-0157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5326
License Number StateTX

VIII. Authorized Official

Name: MARTIN TOMERLIN
Title or Position: PRESIDENT
Credential:
Phone: 210-564-0100