Provider Demographics
NPI:1093371064
Name:GARDENDALE HH OPCO LLC
Entity Type:Organization
Organization Name:GARDENDALE HH OPCO LLC
Other - Org Name:GARDENDALE HEALTHCARE RESIDENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-396-3462
Mailing Address - Street 1:1521 E RUSK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-5505
Mailing Address - Country:US
Mailing Address - Phone:888-396-3462
Mailing Address - Fax:214-396-3482
Practice Address - Street 1:1521 E RUSK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-5505
Practice Address - Country:US
Practice Address - Phone:903-586-3626
Practice Address - Fax:903-586-2766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-15
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004986OtherSTATE FACILITY LICENSE