Provider Demographics
NPI:1255497137
Name:MSHC THE WATERTON AT COWHORN CREEK, LLC
Entity Type:Organization
Organization Name:MSHC THE WATERTON AT COWHORN CREEK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:POWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-534-8667
Mailing Address - Street 1:1901 RICKETY LN
Mailing Address - Street 2:STE 208
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1703
Mailing Address - Country:US
Mailing Address - Phone:903-534-8667
Mailing Address - Fax:903-509-0026
Practice Address - Street 1:5524 COWHORN CREEK RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-9101
Practice Address - Country:US
Practice Address - Phone:903-228-1188
Practice Address - Fax:903-838-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115905314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001013766Medicaid
TX001013766Medicaid