Provider Demographics
NPI:1336515832
Name:HIGHLAND PARK SENIOR CARE 3, LLC
Entity Type:Organization
Organization Name:HIGHLAND PARK SENIOR CARE 3, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:LOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-456-2574
Mailing Address - Street 1:905 PEGUES PL
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-4027
Mailing Address - Country:US
Mailing Address - Phone:903-753-1000
Mailing Address - Fax:903-753-1218
Practice Address - Street 1:905 PEGUES PL
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-4027
Practice Address - Country:US
Practice Address - Phone:903-753-1000
Practice Address - Fax:903-753-1218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX005398251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX024337001Medicaid
TX459294Medicare Oscar/Certification