Healthcare Provider Details

I. General information

NPI: 1013914191
Provider Name (Legal Business Name): PROVIDER HEALTHCARE SERVICES OF LULING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 N MAGNOLIA AVE
LULING TX
78648-1604
US

IV. Provider business mailing address

1105 N MAGNOLIA AVE P. O. BOX 1066
LULING TX
78648-1604
US

V. Phone/Fax

Practice location:
  • Phone: 830-875-5606
  • Fax: 830-875-5857
Mailing address:
  • Phone: 830-875-5606
  • Fax: 830-875-5857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number005045
License Number StateTX

VIII. Authorized Official

Name: MR. TED MORGAN
Title or Position: AGENT
Credential:
Phone: 512-343-9070