Healthcare Provider Details

I. General information

NPI: 1992747430
Provider Name (Legal Business Name): PHCC-MYSTIC PARK REHABILITATION AND HEALTH CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8503 MYSTIC PARK
SAN ANTONIO TX
78254-2544
US

IV. Provider business mailing address

8503 MYSTIC PARK
SAN ANTONIO TX
78254-2544
US

V. Phone/Fax

Practice location:
  • Phone: 210-256-0906
  • Fax: 210-256-0925
Mailing address:
  • Phone: 210-256-0906
  • Fax: 210-256-0925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number113652
License Number StateTX

VIII. Authorized Official

Name: MR. JAMES ARTHUR MEYERS JR.
Title or Position: PRESIDENT, CFO
Credential:
Phone: 210-545-6320