Provider Demographics
NPI:1215038278
Name:LEGEND GREENVILLE HEALTHCARE, LLC
Entity Type:Organization
Organization Name:LEGEND GREENVILLE HEALTHCARE, LLC
Other - Org Name:LEGEND HEALTHCARE AND REHABILITATION - GREENVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-564-0100
Mailing Address - Street 1:1390 E BITTERS RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2914
Mailing Address - Country:US
Mailing Address - Phone:210-564-0100
Mailing Address - Fax:210-564-0157
Practice Address - Street 1:2300 JACK FINNEY BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402-3763
Practice Address - Country:US
Practice Address - Phone:903-455-7942
Practice Address - Fax:903-455-0472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4887314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001004084Medicaid
TX001004084Medicaid