Provider Demographics
NPI:1326143587
Name:LIVE OAK INN, INC
Entity Type:Organization
Organization Name:LIVE OAK INN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-990-4391
Mailing Address - Street 1:619 W LIVE OAK ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-4415
Mailing Address - Country:US
Mailing Address - Phone:830-997-4391
Mailing Address - Fax:830-990-9711
Practice Address - Street 1:619 W LIVE OAK ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4415
Practice Address - Country:US
Practice Address - Phone:830-997-4391
Practice Address - Fax:830-990-9711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4204314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676075Medicare ID - Type UnspecifiedMEDICARE