=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316375173
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARLANDWOOD EAST SCC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2013
-----------------------------------------------------
Last Update Date | 03/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1511 MARLANDWOOD RD
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76502-3338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-899-6500
-----------------------------------------------------
Fax | 254-899-6599
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 N PEARL ST STE 1050
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75201-7495
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-252-7600
-----------------------------------------------------
Fax | 214-252-7704
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MICHAEL BEAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-252-7600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------