Provider Demographics
NPI:1124412077
Name:5423 HAMILTON WOLFE ROAD OPERATIONS LLC
Entity Type:Organization
Organization Name:5423 HAMILTON WOLFE ROAD OPERATIONS LLC
Other - Org Name:POWERBACK REHABILITATION SAN ANTONIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:5423 HAMILTON WOLFE RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4344
Mailing Address - Country:US
Mailing Address - Phone:210-694-9494
Mailing Address - Fax:
Practice Address - Street 1:5423 HAMILTON WOLFE RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4344
Practice Address - Country:US
Practice Address - Phone:210-694-9494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-27
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX144843314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001027706Medicaid
TX001027706Medicaid