Healthcare Provider Details

I. General information

NPI: 1255497137
Provider Name (Legal Business Name): MSHC THE WATERTON AT COWHORN CREEK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5524 COWHORN CREEK RD
TEXARKANA TX
75503-9101
US

IV. Provider business mailing address

1901 RICKETY LN STE 208
TYLER TX
75703-1703
US

V. Phone/Fax

Practice location:
  • Phone: 903-228-1188
  • Fax: 903-838-1229
Mailing address:
  • Phone: 903-534-8667
  • Fax: 903-509-0026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number115905
License Number StateTX

VIII. Authorized Official

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