Healthcare Provider Details

I. General information

NPI: 1639373061
Provider Name (Legal Business Name): ITASCA LONG TERM CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 N FILES ST
ITASCA TX
76055-2336
US

IV. Provider business mailing address

526 TEXAS PT
SAN ANTONIO TX
78258-7738
US

V. Phone/Fax

Practice location:
  • Phone: 254-687-2383
  • Fax:
Mailing address:
  • Phone: 210-316-7790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID LAIN BYERS
Title or Position: MANAGER
Credential:
Phone: 210-316-7790