Provider Demographics
NPI:1497042501
Name:LAS JACARANDAS ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:LAS JACARANDAS ASSISTED LIVING, LLC
Other - Org Name:LAS JACARANDAS HEALTHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:MARTINEZ
Authorized Official - Last Name:BARRIENTES
Authorized Official - Suffix:
Authorized Official - Credentials:MSN,APRN,FNP-BC
Authorized Official - Phone:956-550-0999
Mailing Address - Street 1:645 VILLA MARIA BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-6371
Mailing Address - Country:US
Mailing Address - Phone:956-550-0999
Mailing Address - Fax:956-550-0993
Practice Address - Street 1:645 VILLA MARIA BLVD STE B
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-6371
Practice Address - Country:US
Practice Address - Phone:956-550-0999
Practice Address - Fax:956-550-0993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-09
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 251E00000X, 253Z00000X
TX0143043747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001026799OtherPERSONAL ATTENDANT SERVICES
TX001026799Medicaid