Provider Demographics
NPI:1477748010
Name:BRECKENRIDGE VILLAGE
Entity Type:Organization
Organization Name:BRECKENRIDGE VILLAGE
Other - Org Name:BRECKENRIDGE VILLAGE OF TYLER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-596-8100
Mailing Address - Street 1:15062 COUNTY ROAD 1145
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75704-7516
Mailing Address - Country:US
Mailing Address - Phone:903-956-8100
Mailing Address - Fax:903-956-8104
Practice Address - Street 1:15062 COUNTY ROAD 1145
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75704-7516
Practice Address - Country:US
Practice Address - Phone:903-956-8100
Practice Address - Fax:903-956-8104
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAPTIST CHILD & FAMILY SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-06
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities