Healthcare Provider Details

I. General information

NPI: 1396800389
Provider Name (Legal Business Name): MSHC COLONIAL LODGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 ELIZABETH ST
TEXARKANA TX
75503-2913
US

IV. Provider business mailing address

1901 RICKETY LN STE 208
TYLER TX
75703-1702
US

V. Phone/Fax

Practice location:
  • Phone: 903-792-0838
  • Fax: 903-793-4562
Mailing address:
  • Phone: 903-534-8667
  • Fax: 903-509-0026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number114502
License Number StateTX

VIII. Authorized Official

Name: CARLA POWER
Title or Position: CFO
Credential:
Phone: 903-534-8667