Provider Demographics
NPI:1346544855
Name:MODERN SENIOR LIVING LLC
Entity Type:Organization
Organization Name:MODERN SENIOR LIVING LLC
Other - Org Name:SOUTH DALLAS NURSING AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:P
Authorized Official - Last Name:ISSAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-669-1243
Mailing Address - Street 1:4124 GUS THOMASSON ROAD
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3808 S CENTRAL EXPY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75215-3701
Practice Address - Country:US
Practice Address - Phone:214-428-5851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4607Medicaid
TX675440OtherMEDICARE PTAN