Provider Demographics
NPI:1679554018
Name:OAKLAND MANOR NURSING CENTER, LP
Entity Type:Organization
Organization Name:OAKLAND MANOR NURSING CENTER, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MDS / PPS NURSE
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:979-542-1755
Mailing Address - Street 1:1400 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GIDDINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78942-1360
Mailing Address - Country:US
Mailing Address - Phone:979-542-1755
Mailing Address - Fax:979-542-7002
Practice Address - Street 1:1400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GIDDINGS
Practice Address - State:TX
Practice Address - Zip Code:78942-1360
Practice Address - Country:US
Practice Address - Phone:979-542-1755
Practice Address - Fax:979-542-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108720314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX675101Medicare ID - Type Unspecified