Provider Demographics
NPI:1629135975
Name:PARK PLACE TYLER HEALTHCARE, LLC
Entity Type:Organization
Organization Name:PARK PLACE TYLER HEALTHCARE, LLC
Other - Org Name:PARK PLACE NURSING & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REIMBURSEMENT SPECIALISTS
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:REDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-881-9432
Mailing Address - Street 1:2450 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-3525
Mailing Address - Country:US
Mailing Address - Phone:903-592-6745
Mailing Address - Fax:903-592-1088
Practice Address - Street 1:2450 E 5TH ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-3525
Practice Address - Country:US
Practice Address - Phone:903-592-6745
Practice Address - Fax:903-592-1088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001012142Medicaid
TX5390Medicaid
TX001012142Medicaid