Healthcare Provider Details

I. General information

NPI: 1780966143
Provider Name (Legal Business Name): LAREDO OPERATOR LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 TOURNAMENT TRAIL DRIVE
LAREDO TX
78041
US

IV. Provider business mailing address

1020 NE LOOP 410 SUITE 640
SAN ANTONIO TX
78209-1204
US

V. Phone/Fax

Practice location:
  • Phone: 210-828-5686
  • Fax: 210-798-0725
Mailing address:
  • Phone: 210-828-5686
  • Fax: 210-798-0725

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. CARL FELLBAUM
Title or Position: CEO
Credential:
Phone: 210-828-5686