Healthcare Provider Details

I. General information

NPI: 1558960070
Provider Name (Legal Business Name): BLANCO VILLA OP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8020 BLANCO RD
SAN ANTONIO TX
78216-3702
US

IV. Provider business mailing address

8020 BLANCO RD
SAN ANTONIO TX
78216-3702
US

V. Phone/Fax

Practice location:
  • Phone: 210-344-4553
  • Fax: 210-366-3728
Mailing address:
  • Phone: 210-344-4553
  • Fax: 210-366-3728

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: SAMUEL GOLDNER
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 210-344-4553