Healthcare Provider Details

I. General information

NPI: 1962327197
Provider Name (Legal Business Name): 902 E MAIN ST TX15 OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 E MAIN ST
SAN AUGUSTINE TX
75972-2316
US

IV. Provider business mailing address

902 E MAIN ST
SAN AUGUSTINE TX
75972-2316
US

V. Phone/Fax

Practice location:
  • Phone: 936-275-2055
  • Fax:
Mailing address:
  • Phone: 936-275-2055
  • Fax:

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: JARED ELLIOTT
Title or Position: CEO
Credential:
Phone: 718-916-1443