Provider Demographics
NPI:1477879401
Name:PHCC-BRODIE RANCH REHABILITATION & HEALTH CARE CENTER, LLC
Entity Type:Organization
Organization Name:PHCC-BRODIE RANCH REHABILITATION & HEALTH CARE CENTER, LLC
Other - Org Name:SOUTH OAKS REHABILITATION AND HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:MEYERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:210-545-6320
Mailing Address - Street 1:19115 FM 2252
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GARDEN RIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:78266-2577
Mailing Address - Country:US
Mailing Address - Phone:210-545-6320
Mailing Address - Fax:210-545-2730
Practice Address - Street 1:2101 FRATE BARKER ROAD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-3614
Practice Address - Country:US
Practice Address - Phone:210-545-6320
Practice Address - Fax:210-545-2730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPENDING314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid
TXPENDINGMedicare Oscar/Certification