Healthcare Provider Details

I. General information

NPI: 1053876771
Provider Name (Legal Business Name): LS MINEOLA OPERATOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2019
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 MIMOSA DR
MINEOLA TX
75773-2612
US

IV. Provider business mailing address

716 MIMOSA DR
MINEOLA TX
75773-2612
US

V. Phone/Fax

Practice location:
  • Phone: 903-569-5366
  • Fax:
Mailing address:
  • Phone: 903-569-5366
  • Fax: 903-569-9050

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: MARK LAZAR
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 323-651-1808