Provider Demographics
NPI:1083088959
Name:RIO ONE AT TARRANT COUNTY, LLC
Entity Type:Organization
Organization Name:RIO ONE AT TARRANT COUNTY, LLC
Other - Org Name:THE LODGE AT BEAR CREEK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-369-0079
Mailing Address - Street 1:8820 HORIZON BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1689
Mailing Address - Country:US
Mailing Address - Phone:505-369-0079
Mailing Address - Fax:
Practice Address - Street 1:3729 IRA E WOODS AVE
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4213
Practice Address - Country:US
Practice Address - Phone:817-809-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-16
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001027384Medicaid
TX802160926OtherSTATE LICENSE