Provider Demographics
NPI:1689662488
Name:TEXARKANA ELDER SERVICES, INC. DBA EDGEWOOD MANOR NURSING HOME
Entity Type:Organization
Organization Name:TEXARKANA ELDER SERVICES, INC. DBA EDGEWOOD MANOR NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:DESHOTELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-773-2376
Mailing Address - Street 1:4925 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2911
Mailing Address - Country:US
Mailing Address - Phone:903-793-4645
Mailing Address - Fax:903-793-3956
Practice Address - Street 1:4925 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2911
Practice Address - Country:US
Practice Address - Phone:903-793-4645
Practice Address - Fax:903-793-3956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113456314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX005150OtherFACILITY #
TX113456Medicaid
TX113456Medicaid