Provider Demographics
NPI:1477694545
Name:AZALEA PLACE OPERATING COMPANY
Entity Type:Organization
Organization Name:AZALEA PLACE OPERATING COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-593-2463
Mailing Address - Street 1:810 S PORTER AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2300
Mailing Address - Country:US
Mailing Address - Phone:903-593-2463
Mailing Address - Fax:903-597-1203
Practice Address - Street 1:810 S PORTER AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2300
Practice Address - Country:US
Practice Address - Phone:903-593-2463
Practice Address - Fax:903-597-1203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4734314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4734OtherVENDOR ID#
TX675912Medicare ID - Type UnspecifiedPROVIDER