MEDICARE: BLUEBONNET SNF 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	332BN1400X	Nursing Facility Supplies (DME)
2	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1700112190
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEBONNET SNF LLC

Provider Business Mailing Address
First Line	:	2225 E RANDOL MILL RD
Second Line	:	STE 630
City	:	ARLINGTON
State	:	TX
Zip	:	76011-6315
Country	:	US
Telephone Number	:	817-607-7400
Fax Number	:

Provider Business Practice Location Address
First Line	:	724 HIGHWAY 283
Second Line	:
City	:	ALBANY
State	:	TX
Zip	:	76430-0608
Country	:	US
Telephone Number	:	915-762-3329
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	ZEVI KOHN
Credential	:
Telephone Number	:	917-370-9063

Provider Enumeration Date	:	10/20/2009
Last Update Date	:	02/17/2010

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