Healthcare Provider Details

I. General information

NPI: 1437194032
Provider Name (Legal Business Name): LUFKIN LTC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 N JOHN REDDITT DR
LUFKIN TX
75904-2644
US

IV. Provider business mailing address

504 N JOHN REDDITT DR
LUFKIN TX
75904-2644
US

V. Phone/Fax

Practice location:
  • Phone: 936-632-3331
  • Fax: 936-634-1611
Mailing address:
  • Phone: 936-632-3331
  • Fax: 936-634-1611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number107684
License Number StateTX

VIII. Authorized Official

Name: JAKE HALLSTED
Title or Position: PRESIDENT
Credential:
Phone: 832-448-3700