Provider Demographics
NPI:1396205852
Name:DSL TENANT II LLC
Entity Type:Organization
Organization Name:DSL TENANT II LLC
Other - Org Name:DISCOVERY VILLAGE AT SOUTHLAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-301-5311
Mailing Address - Street 1:27599 RIVERVIEW CENTER BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4327
Mailing Address - Country:US
Mailing Address - Phone:239-908-2921
Mailing Address - Fax:
Practice Address - Street 1:201 WATERMERE DR
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-8137
Practice Address - Country:US
Practice Address - Phone:817-482-1340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-21
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility