MEDICARE: POLK NURSING HOME LIMITED PARTNERSHIP

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	313M00000X	Nursing Facility/Intermediate Care Facility	113278	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HH2664	OTHER	TX	BCBS OF TEXAS

General Provider Information

NPI Number	:	1487641296
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POLK NURSING HOME LIMITED PARTNERSHIP

Provider Business Mailing Address
First Line	:	RR 2
Second Line	:	HIGHWAY 59 NORTH BYPASS
City	:	LIVINGSTON
State	:	TX
Zip	:	77351-9802
Country	:	US
Telephone Number	:	936-327-4446
Fax Number	:	936-327-8435

Provider Business Practice Location Address
First Line	:	6633 E HIGHWAY 290
Second Line	:	SUITE # 202
City	:	AUSTIN
State	:	TX
Zip	:	78723-1172
Country	:	US
Telephone Number	:	512-458-5707
Fax Number	:	512-458-5751

Authorized Official
Title or Position	:	CEO
Name	:	MR. MARK HIMMEL
Credential	:
Telephone Number	:	512-458-5707

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	08/22/2020

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Directions to “POLK NURSING HOME LIMITED PARTNERSHIP ” Practice Location

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