MEDICARE: WESTWARD TRAILS OPERATOR 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	133763	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	005305	OTHER	TX	FACILITY ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770630626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTWARD TRAILS OPERATOR LLC

Provider Business Mailing Address
First Line	:	3001 WESTWARD DR
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75964-1232
Country	:	US
Telephone Number	:	936-569-2631
Fax Number	:	936-569-0590

Provider Business Practice Location Address
First Line	:	3001 WESTWARD DR
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75964-1232
Country	:	US
Telephone Number	:	936-569-2631
Fax Number	:	936-569-0590

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	SHERYL SMITH
Credential	:
Telephone Number	:	936-569-2631

Provider Enumeration Date	:	01/04/2007
Last Update Date	:	03/26/2012

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