Provider Demographics
NPI:1093847378
Name:DIVERSIFIED HEALTHCARE-DALLAS LLC
Entity Type:Organization
Organization Name:DIVERSIFIED HEALTHCARE-DALLAS LLC
Other - Org Name:BROOKHAVEN NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-394-7141
Mailing Address - Street 1:1855 CHEYENNE DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-2201
Mailing Address - Country:US
Mailing Address - Phone:972-394-7141
Mailing Address - Fax:972-492-5534
Practice Address - Street 1:1855 CHEYENNE DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-2201
Practice Address - Country:US
Practice Address - Phone:972-394-7141
Practice Address - Fax:972-492-5534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118368314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001013833Medicaid
TX001013833Medicaid
TX455412Medicare Oscar/Certification