=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902026446
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RED BIRD MANOR LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 956 FM RD 757
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-566-9665
-----------------------------------------------------
Fax | 903-566-2419
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 956 FM RD 757
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-566-9665
-----------------------------------------------------
Fax | 903-566-2419
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. CAROL E SCOTT HAWKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-566-9665
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 000933
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------