Provider Demographics
NPI:1588022057
Name:SHADY SHORES OF CORPUS CHRISTI LLC
Entity Type:Organization
Organization Name:SHADY SHORES OF CORPUS CHRISTI LLC
Other - Org Name:VISTA DEL MAR HEALTH & REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-422-1622
Mailing Address - Street 1:320 EAGLE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-6898
Mailing Address - Country:US
Mailing Address - Phone:214-422-1622
Mailing Address - Fax:972-755-6795
Practice Address - Street 1:1314 3RD ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2208
Practice Address - Country:US
Practice Address - Phone:361-888-5511
Practice Address - Fax:361-888-6267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-29
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility