MEDICARE: MODERN SENIOR LIVING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	675440	OTHER	TX	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346544855
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN SENIOR LIVING LLC

Provider Business Mailing Address
First Line	:	4124 GUS THOMASSON ROAD
Second Line	:
City	:	MESQUITE
State	:	TX
Zip	:	75150
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3808 S CENTRAL EXPY
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75215-3701
Country	:	US
Telephone Number	:	214-428-5851
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. TROY P ISSAC
Credential	:
Telephone Number	:	972-669-1243

Provider Enumeration Date	:	12/28/2010
Last Update Date	:	01/18/2021

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Directions to “MODERN SENIOR LIVING LLC ” Practice Location

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