Healthcare Provider Details

I. General information

NPI: 1629135975
Provider Name (Legal Business Name): PARK PLACE TYLER HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 E 5TH ST
TYLER TX
75701-3525
US

IV. Provider business mailing address

2450 E 5TH ST
TYLER TX
75701-3525
US

V. Phone/Fax

Practice location:
  • Phone: 903-592-6745
  • Fax: 903-592-1088
Mailing address:
  • Phone: 903-592-6745
  • Fax: 903-592-1088

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: MS. SHARON KAY REDD
Title or Position: REIMBURSEMENT SPECIALISTS
Credential:
Phone: 903-881-9432