Provider Demographics
NPI:1619977246
Name:THE CUMBERLAND REST INC
Entity Type:Organization
Organization Name:THE CUMBERLAND REST INC
Other - Org Name:TRINITY TERRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOLTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-646-3422
Mailing Address - Street 1:1600 TEXAS ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-3400
Mailing Address - Country:US
Mailing Address - Phone:817-338-2400
Mailing Address - Fax:817-335-2733
Practice Address - Street 1:1600 TEXAS ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-3400
Practice Address - Country:US
Practice Address - Phone:817-338-2400
Practice Address - Fax:817-335-2733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111033314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX675238Medicare ID - Type Unspecified