Provider Demographics
NPI:1609206077
Name:BROADMOOR CONTINUING CARE CENTER LTD. CO.
Entity Type:Organization
Organization Name:BROADMOOR CONTINUING CARE CENTER LTD. CO.
Other - Org Name:THE BROADMOOR AT CREEKSIDE PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LEGAL ASSISTANT/CLAIMS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-954-4114
Mailing Address - Street 1:2537 GOLDEN BEAR DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-2377
Mailing Address - Country:US
Mailing Address - Phone:214-954-4114
Mailing Address - Fax:214-880-0053
Practice Address - Street 1:5665 CREEKSIDE FOREST DR
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77389-4969
Practice Address - Country:US
Practice Address - Phone:281-255-8180
Practice Address - Fax:281-255-8190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-20
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001025592Medicaid
TX676357Medicare Oscar/Certification