Provider Demographics
NPI:1477860435
Name:PROGRESSIVE LIFE, LTD
Entity Type:Organization
Organization Name:PROGRESSIVE LIFE, LTD
Other - Org Name:PROGRESSIVE LIFE OF CENTRAL TEXAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-340-7155
Mailing Address - Street 1:2579 WESTERN TRAILS BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1578
Mailing Address - Country:US
Mailing Address - Phone:512-892-2191
Mailing Address - Fax:
Practice Address - Street 1:17016 COPPERHEAD DR
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-8616
Practice Address - Country:US
Practice Address - Phone:512-892-2191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001008861Medicaid