Healthcare Provider Details

I. General information

NPI: 1205572641
Provider Name (Legal Business Name): MEADOW LAKE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 06/30/2023
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16044 COUNTY ROAD 165
TYLER TX
75703-7302
US

IV. Provider business mailing address

15601 DALLAS PKWY
ADDISON TX
75001-3353
US

V. Phone/Fax

Practice location:
  • Phone: 903-526-5599
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS HARSHFIELD
Title or Position: VICE PRESIDENT & CFO
Credential:
Phone: 515-288-5805