Provider Demographics
NPI:1558539205
Name:MSPF II GRANBURY O.E., L.P.
Entity Type:Organization
Organization Name:MSPF II GRANBURY O.E., L.P.
Other - Org Name:HARBOR LAKES PLAZA NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RONCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-651-4050
Mailing Address - Street 1:3811 TURTLE CREEK BLVD
Mailing Address - Street 2:SUITE 1850
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-4402
Mailing Address - Country:US
Mailing Address - Phone:214-651-4050
Mailing Address - Fax:214-651-4001
Practice Address - Street 1:1300 2ND ST
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-1496
Practice Address - Country:US
Practice Address - Phone:817-408-3800
Practice Address - Fax:817-573-0165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX124179314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001016065Medicaid
TX103435OtherDADS FACILITY ID
TX103435OtherDADS FACILITY ID