=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982606174
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CASCADE ANGELINA HEALTH SERVICES, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2414 W FRANK AVE
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75904-3521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-699-2544
-----------------------------------------------------
Fax | 936-699-3355
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2414 W FRANK AVE
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75904-3521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-699-2544
-----------------------------------------------------
Fax | 936-699-3355
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL PARTNER
-----------------------------------------------------
Name | MR. RONALD M HANEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 936-634-6633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 113565
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------