=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831286020
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THI OF TEXAS AT SWAN MANOR, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2508 WARD RD
-----------------------------------------------------
City | BAYTOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77520-8103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-422-9030
-----------------------------------------------------
Fax | 281-420-0780
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 930 RIDGEBROOK RD
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21152-9390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-773-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | VIRGINIA WALTERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-422-9030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 117545
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------