MEDICARE: S.U.R. 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	127476	TX

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
2	004892	OTHER	TX	FACILITY ID

General Provider Information

NPI Number	:	1659514867
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S.U.R. LLC

Provider Business Mailing Address
First Line	:	9450 FM 2210 E
Second Line	:
City	:	POOLVILLE
State	:	TX
Zip	:	76487-5028
Country	:	US
Telephone Number	:	940-374-3804
Fax Number	:	940-374-3069

Provider Business Practice Location Address
First Line	:	2630 OLD ANSON RD
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79603-2210
Country	:	US
Telephone Number	:	325-673-5101
Fax Number	:	325-673-0568

Authorized Official
Title or Position	:	VP OF OPERATIONS
Name	:	MONTE RANDALL
Credential	:
Telephone Number	:	940-374-3804

Provider Enumeration Date	:	04/17/2009
Last Update Date	:	01/12/2010

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