MEDICARE: HOLLAND LAKE NURSING CENTER LTD

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	113174	TX

General Provider Information

NPI Number	:	1669477147
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLAND LAKE NURSING CENTER LTD

Provider Business Mailing Address
First Line	:	PO BOX 122267
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76121-2267
Country	:	US
Telephone Number	:	817-598-0160
Fax Number	:	817-598-0162

Provider Business Practice Location Address
First Line	:	1201 HOLLAND LAKE DR
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-5851
Country	:	US
Telephone Number	:	817-598-0160
Fax Number	:	817-598-0162

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MRS. SUE HAYES
Credential	:
Telephone Number	:	817-598-0160

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	08/22/2020

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