Healthcare Provider Details

I. General information

NPI: 1780681643
Provider Name (Legal Business Name): SHADY OAK NURSING AND REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 11/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SOUTH LANCASTER
MOULTON TX
77975-0120
US

IV. Provider business mailing address

PO BOX 7230
VICTORIA TX
77903-7230
US

V. Phone/Fax

Practice location:
  • Phone: 361-596-7373
  • Fax: 361-596-7671
Mailing address:
  • Phone: 361-576-9454
  • Fax: 361-576-2994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number111107
License Number StateTX

VIII. Authorized Official

Name: MR. BYRON M BURRIS II
Title or Position: PRESIDENT
Credential: LNFA
Phone: 361-576-9454