Provider Demographics
NPI:1427360569
Name:CSL 108TH & Q, LLC
Entity Type:Organization
Organization Name:CSL 108TH & Q, LLC
Other - Org Name:THE WATERFORD AT ROXBURY PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP-FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-770-5600
Mailing Address - Street 1:14160 DALLAS PARKWAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254
Mailing Address - Country:US
Mailing Address - Phone:972-770-5600
Mailing Address - Fax:972-770-5666
Practice Address - Street 1:5728 S. 108TH STREET
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137
Practice Address - Country:US
Practice Address - Phone:402-537-0544
Practice Address - Fax:402-593-8010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEALF155310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100258494-00Medicaid