Healthcare Provider Details

I. General information

NPI: 1750719068
Provider Name (Legal Business Name): LEGEND OAKS - GRANITE MESA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2013
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 MAX COPELAND DR
MARBLE FALLS TX
78654-4665
US

IV. Provider business mailing address

1390 E BITTERS RD
SAN ANTONIO TX
78216-2914
US

V. Phone/Fax

Practice location:
  • Phone: 830-693-0022
  • Fax:
Mailing address:
  • Phone:
  • 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: THOMAS MARTIN TOMERLIN
Title or Position: PRESIDENT/COO/MANAGER
Credential:
Phone: 210-564-0100