Provider Demographics
NPI:1366457723
Name:PROVIDER HEALTHCARE SERVICES OF LULING, LLC
Entity Type:Organization
Organization Name:PROVIDER HEALTHCARE SERVICES OF LULING, LLC
Other - Org Name:OAKCREEK NURSING AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TED
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-343-9070
Mailing Address - Street 1:3420 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-1624
Mailing Address - Country:US
Mailing Address - Phone:512-343-9070
Mailing Address - Fax:512-343-1060
Practice Address - Street 1:1105 N MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:TX
Practice Address - Zip Code:78648-1604
Practice Address - Country:US
Practice Address - Phone:830-875-5606
Practice Address - Fax:830-875-5857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117854314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1014325Medicaid
TX1014325Medicaid