Provider Demographics
NPI:1598801631
Name:RETAMA MANOR DEL RIO LLC
Entity Type:Organization
Organization Name:RETAMA MANOR DEL RIO LLC
Other - Org Name:RETAMA MANOR DEL RIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAMORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-775-7477
Mailing Address - Street 1:930 RIDGEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 HERRMANN DR
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-4125
Practice Address - Country:US
Practice Address - Phone:830-775-7477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001014915Medicaid
TX001014915Medicaid