Provider Demographics
NPI:1497020853
Name:EAST TEXAS ALF WATERTON INN LLC
Entity Type:Organization
Organization Name:EAST TEXAS ALF WATERTON INN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:POWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-792-0838
Mailing Address - Street 1:2885 SHILOH RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-2936
Mailing Address - Country:US
Mailing Address - Phone:903-939-9664
Mailing Address - Fax:
Practice Address - Street 1:2885 SHILOH RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-2936
Practice Address - Country:US
Practice Address - Phone:903-939-9664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX ID