Healthcare Provider Details

I. General information

NPI: 1982886578
Provider Name (Legal Business Name): HSMTX WATERTON PLAZA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 02/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 SHILOH RD
TYLER TX
75703-2936
US

IV. Provider business mailing address

5300 HOLLISTER ST SUITE 550
HOUSTON TX
77040-6137
US

V. Phone/Fax

Practice location:
  • Phone: 903-561-1300
  • Fax: 903-939-1754
Mailing address:
  • Phone: 713-934-7800
  • Fax: 713-895-0064

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: CHARLES A DAVIS
Title or Position: VP FINANCE
Credential:
Phone: 713-934-7800