Provider Demographics
NPI:1134104631
Name:BLENDED HEALTH LLC
Entity Type:Organization
Organization Name:BLENDED HEALTH LLC
Other - Org Name:CYPRESS GLEN EAST NURSING & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:409-962-0910
Mailing Address - Street 1:4225 LAKE ARTHUR DR
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-6490
Mailing Address - Country:US
Mailing Address - Phone:409-727-3193
Mailing Address - Fax:409-727-4777
Practice Address - Street 1:4225 LAKE ARTHUR DR
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-6490
Practice Address - Country:US
Practice Address - Phone:409-727-3193
Practice Address - Fax:409-727-4777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113493314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001012145Medicaid
TX001012145Medicaid