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NPI Code Detail

MEDICARE: CENTURY-EBONY LAKE-GEAC,LLC

MEDICARE: CENTURY-EBONY LAKE-GEAC,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
1314000000XSkilled Nursing Facility112530TX

Other Identifiers

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

General Provider Information

NPI Number : 1740277391
Entity Type Code : Organization
Provider Name (Legal Business Name) : CENTURY-EBONY LAKE-GEAC,LLC
Provider Business Mailing Address
First Line : 1001 CENTRAL BLVD
Second Line :
City : BROWNSVILLE
State : TX
Zip : 78520-7533
Country : US
Telephone Number : 956-541-0917
Fax Number : 956-541-2860
Provider Business Practice Location Address
First Line : 1001 CENTRAL BLVD
Second Line :
City : BROWNSVILLE
State : TX
Zip : 78520-7533
Country : US
Telephone Number : 956-541-0917
Fax Number : 956-541-2860
Authorized Official
Title or Position : OWNER'S REPRESENTATIVE
Name : MS. DIANE M RYAN
Credential : RN,MS
Telephone Number : 952-837-0818
Provider Enumeration Date : 09/29/2005
Last Update Date : 08/22/2020

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