Healthcare Provider Details

I. General information

NPI: 1124412077
Provider Name (Legal Business Name): 5423 HAMILTON WOLFE ROAD OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 10/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5423 HAMILTON WOLFE RD
SAN ANTONIO TX
78229-4344
US

IV. Provider business mailing address

5423 HAMILTON WOLFE RD
SAN ANTONIO TX
78229-4344
US

V. Phone/Fax

Practice location:
  • Phone: 210-694-9494
  • Fax:
Mailing address:
  • Phone: 210-694-9494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number144843
License Number StateTX

VIII. Authorized Official

Name: MICHAEL T. BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4752