MEDICARE: HOLLAND LAKE SCC 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

Other Identifiers

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

General Provider Information

NPI Number	:	1790157519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLAND LAKE SCC LLC

Provider Business Mailing Address
First Line	:	14841 DALLAS PKWY
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75254-7685
Country	:	US
Telephone Number	:	214-252-7600
Fax Number	:

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	:

Authorized Official
Title or Position	:	CHIEF OPERATIONS OFFICER
Name	:	MICHAEL TEMPLETON
Credential	:
Telephone Number	:	214-252-7600

Provider Enumeration Date	:	10/21/2015
Last Update Date	:	03/16/2022

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