Provider Demographics
NPI:1053468082
Name:LUTHERAN SOCIAL SERVICES OF THE SOUTH, INC.
Entity Type:Organization
Organization Name:LUTHERAN SOCIAL SERVICES OF THE SOUTH, INC.
Other - Org Name:WEDGEWOOD SOUTH ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT SENIOR SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERKELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-459-1000
Mailing Address - Street 1:PO BOX 140767
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78714-0767
Mailing Address - Country:US
Mailing Address - Phone:512-459-1000
Mailing Address - Fax:512-452-6855
Practice Address - Street 1:9812 VINTON AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-6376
Practice Address - Country:US
Practice Address - Phone:806-798-1011
Practice Address - Fax:806-794-0234
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN SOCIAL SERVICES OF THE SOUTH, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-04
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX030082310400000X
TX030086310400000X
TX030081310400000X
TX100083310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility