MEDICARE: UNIVERSITY VILLAGE MEMORY CARE

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	310400000X	Assisted Living Facility	104858	TX

General Provider Information

NPI Number	:	1790100436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY VILLAGE MEMORY CARE

Provider Business Mailing Address
First Line	:	4701 CAMPUS VILLAGE DR
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78665-1122
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4701 CAMPUS VILLAGE DR
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78665-1122
Country	:	US
Telephone Number	:	512-248-2222
Fax Number	:

Authorized Official
Title or Position	:	CEO MANAGEMENT COMPANY
Name	:	LOREE TAMAYO
Credential	:
Telephone Number	:	210-326-6662

Provider Enumeration Date	:	03/04/2014
Last Update Date	:	03/04/2014

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