Provider Demographics
NPI:1144394719
Name:WOODLAKE NURSING HOME LLC
Entity Type:Organization
Organization Name:WOODLAKE NURSING HOME LLC
Other - Org Name:WOODLAKE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VEDALIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-265-4221
Mailing Address - Street 1:920 RIDGEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:603 E PLANTATION DR
Practice Address - Street 2:
Practice Address - City:CLUTE
Practice Address - State:TX
Practice Address - Zip Code:77531-5719
Practice Address - Country:US
Practice Address - Phone:979-265-4221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001014699Medicaid
TX001014699Medicaid