=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366457723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDER HEALTHCARE SERVICES OF LULING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1105 N MAGNOLIA AVE
-----------------------------------------------------
City | LULING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78648-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-875-5606
-----------------------------------------------------
Fax | 830-875-5857
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3420 EXECUTIVE CENTER DR SUITE 100
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78731-1624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-343-9070
-----------------------------------------------------
Fax | 512-343-1060
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. TED MORGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-343-9070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 117854
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------