Provider Demographics
NPI:1669477147
Name:HOLLAND LAKE NURSING CENTER LTD
Entity Type:Organization
Organization Name:HOLLAND LAKE NURSING CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-598-0160
Mailing Address - Street 1:PO BOX 122267
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76121-2267
Mailing Address - Country:US
Mailing Address - Phone:817-598-0160
Mailing Address - Fax:817-598-0162
Practice Address - Street 1:1201 HOLLAND LAKE DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5851
Practice Address - Country:US
Practice Address - Phone:817-598-0160
Practice Address - Fax:817-598-0162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113174314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX675633Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER