Healthcare Provider Details

I. General information

NPI: 1790299659
Provider Name (Legal Business Name): WOODGATE SNF REALTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 HORIZON CIR
WACO TX
76712-6985
US

IV. Provider business mailing address

6500 HORIZON CIR
WACO TX
76712-6985
US

V. Phone/Fax

Practice location:
  • Phone: 254-741-5929
  • Fax: 254-741-5928
Mailing address:
  • Phone: 254-741-5929
  • Fax: 254-741-5928

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: JACK COOK
Title or Position: MEMBER
Credential:
Phone: 254-741-5929