Provider Demographics
NPI:1235550591
Name:SANDHILL VERNON, LLC
Entity Type:Organization
Organization Name:SANDHILL VERNON, LLC
Other - Org Name:EAGLE FLATS VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PRABHAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:KERJRIWAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-996-7801
Mailing Address - Street 1:4501 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:76384-4093
Mailing Address - Country:US
Mailing Address - Phone:940-552-8181
Mailing Address - Fax:940-552-6288
Practice Address - Street 1:4501 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:TX
Practice Address - Zip Code:76384-4093
Practice Address - Country:US
Practice Address - Phone:940-552-8181
Practice Address - Fax:940-552-6288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001014752Medicaid