Provider Demographics
NPI:1235668625
Name:RED BEARD LLC
Entity Type:Organization
Organization Name:RED BEARD LLC
Other - Org Name:COUNTRY MANOR ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-776-0703
Mailing Address - Street 1:265 COUNTY ROAD 613
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TX
Mailing Address - Zip Code:77535-4325
Mailing Address - Country:US
Mailing Address - Phone:936-258-6803
Mailing Address - Fax:
Practice Address - Street 1:265 COUNTY ROAD 613
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TX
Practice Address - Zip Code:77535
Practice Address - Country:US
Practice Address - Phone:936-258-6803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX310400000XOtherTEXAS DEPARTMENT OF AGING