Healthcare Provider Details

I. General information

NPI: 1164081352
Provider Name (Legal Business Name): WACO HEALTHCARE RESIDENCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 LAKE SHORE DR
WACO TX
76708-3718
US

IV. Provider business mailing address

111 CLIFTON AVE
LAKEWOOD NJ
08701-3342
US

V. Phone/Fax

Practice location:
  • Phone: 254-753-0291
  • Fax: 254-753-3343
Mailing address:
  • Phone: 888-396-3462
  • Fax: 214-396-3462

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: JOE NEUMAN
Title or Position: MANAGER
Credential:
Phone: 888-396-3462