Provider Demographics
NPI:1487626099
Name:CEDAR CREEK NURSING AND REHABILITATION CENTER, INC
Entity Type:Organization
Organization Name:CEDAR CREEK NURSING AND REHABILITATION CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:UMSHAVENI
Authorized Official - Middle Name:
Authorized Official - Last Name:GOVENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-757-5115
Mailing Address - Street 1:PO BOX 185159
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76181-0159
Mailing Address - Country:US
Mailing Address - Phone:972-757-5115
Mailing Address - Fax:817-284-0409
Practice Address - Street 1:159 MONTAGUE DRIVE
Practice Address - Street 2:
Practice Address - City:BANDERA
Practice Address - State:TX
Practice Address - Zip Code:78003
Practice Address - Country:US
Practice Address - Phone:830-460-3767
Practice Address - Fax:830-796-4791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001012682Medicaid
TX67-5929Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER