Provider Demographics
NPI:1578515201
Name:SENIOR LIVING PROPERTIES LLC
Entity Type:Organization
Organization Name:SENIOR LIVING PROPERTIES LLC
Other - Org Name:COUNTRY INN HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KEYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-410-7300
Mailing Address - Street 1:PO BOX 1389
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76099-1389
Mailing Address - Country:US
Mailing Address - Phone:817-410-7300
Mailing Address - Fax:817-810-7411
Practice Address - Street 1:1085 E MAIN ST
Practice Address - Street 2:
Practice Address - City:VAN
Practice Address - State:TX
Practice Address - Zip Code:75790-2949
Practice Address - Country:US
Practice Address - Phone:903-963-8646
Practice Address - Fax:903-963-5031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116017314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004299OtherFACILITY ID NO.
TX45-5966Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
TX1248470087Medicare NSC