MEDICARE: LEGEND OAKS - SOUTH SAN ANTONIO, 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	5487	TX

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	:	1871516609
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGEND OAKS - SOUTH SAN ANTONIO, LLC

Provider Business Mailing Address
First Line	:	1390 E BITTERS RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-2914
Country	:	US
Telephone Number	:	210-564-0100
Fax Number	:	210-564-0157

Provider Business Practice Location Address
First Line	:	2003 W. HUTCHINS PL
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78224-1368
Country	:	US
Telephone Number	:	210-927-0827
Fax Number	:	210-927-0806

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARTIN TOMERLIN
Credential	:
Telephone Number	:	210-564-0100

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	03/26/2015

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