Healthcare Provider Details

I. General information

NPI: 1720003536
Provider Name (Legal Business Name): LEGEND OAKS - SAN ANGELO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5455 KNICKERBOCKER RD
SAN ANGELO TX
76904-7711
US

IV. Provider business mailing address

5455 KNICKERBOCKER RD
SAN ANGELO TX
76904-7711
US

V. Phone/Fax

Practice location:
  • Phone: 325-944-1600
  • Fax: 325-944-1660
Mailing address:
  • Phone: 325-944-1600
  • Fax: 325-944-1660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5472
License Number StateTX

VIII. Authorized Official

Name: MARTIN TOMERLIN
Title or Position: PRESIDENT
Credential:
Phone: 210-564-0100