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General NPI Number Information
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NPI Number | 1740277391
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Entity Type | Organization
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Legal Business Name | CENTURY-EBONY LAKE-GEAC,LLC
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Dates
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Enumeration Date | 09/29/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1001 CENTRAL BLVD
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City | BROWNSVILLE
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State | TX
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Zip | 78520-7533
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Country | US
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Telephone | 956-541-0917
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Fax | 956-541-2860
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Provider Business Mailing Address
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Address Line | 1001 CENTRAL BLVD
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City | BROWNSVILLE
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State | TX
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Zip | 78520-7533
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Country | US
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Telephone | 956-541-0917
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Fax | 956-541-2860
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Authorized Official
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Title or Position | OWNER'S REPRESENTATIVE
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Name | MS. DIANE M RYAN
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Credential | RN,MS
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Telephone | 952-837-0818
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 112530
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License Number State | TX
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