Provider Demographics
NPI:1144580192
Name:EAGLE'S TRACE INC
Entity Type:Organization
Organization Name:EAGLE'S TRACE INC
Other - Org Name:CONTINUING CARE AT EAGLE'S TRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-402-2315
Mailing Address - Street 1:14703 EAGLE VISTA DR
Mailing Address - Street 2:ATTN: EXECUTIVE DIRECTOR
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-5394
Mailing Address - Country:US
Mailing Address - Phone:281-249-7000
Mailing Address - Fax:410-204-7237
Practice Address - Street 1:14703 EAGLE VISTA DR
Practice Address - Street 2:ATTN: EXTENDED CARE ADMINISTRATOR
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-5394
Practice Address - Country:US
Practice Address - Phone:281-249-7099
Practice Address - Fax:410-204-7237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX136818314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676336Medicare Oscar/Certification