Healthcare Provider Details

I. General information

NPI: 1922483064
Provider Name (Legal Business Name): SHADY SHORES OF REFUGIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 SWIFT ST
REFUGIO TX
78377-2428
US

IV. Provider business mailing address

320 EAGLE DR SUITE 201
DENTON TX
76201-6898
US

V. Phone/Fax

Practice location:
  • Phone: 361-526-4641
  • Fax:
Mailing address:
  • Phone: 940-228-1414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL WALLACE
Title or Position: CEO
Credential:
Phone: 214-422-1622