Provider Demographics
NPI:1518036987
Name:SSC NUECES RETAMA LLC
Entity Type:Organization
Organization Name:SSC NUECES RETAMA LLC
Other - Org Name:RETAMA MANOR NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR DIRECTOR ACCOUNTS RECIEVABLE
Authorized Official - Prefix:
Authorized Official - First Name:KELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SANTORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-467-5728
Mailing Address - Street 1:5300 W SAM HOUSTON PKWY N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-5161
Mailing Address - Country:US
Mailing Address - Phone:832-467-6000
Mailing Address - Fax:
Practice Address - Street 1:2322 MORGAN AVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-1947
Practice Address - Country:US
Practice Address - Phone:361-882-4242
Practice Address - Fax:361-883-3726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118447314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001014485Medicaid
TX455575Medicare Oscar/Certification