Provider Demographics
NPI:1689868861
Name:SUBTENANT 3611 DICKASON AVENUE, LLC
Entity Type:Organization
Organization Name:SUBTENANT 3611 DICKASON AVENUE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:C
Authorized Official - Last Name:OBORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-240-7200
Mailing Address - Street 1:3611 DICKASON AVENUE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-4912
Mailing Address - Country:US
Mailing Address - Phone:214-559-0140
Mailing Address - Fax:214-559-0171
Practice Address - Street 1:3611 DICKASON AVENUE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-4912
Practice Address - Country:US
Practice Address - Phone:214-559-0140
Practice Address - Fax:214-559-0171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X
TX130513314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001019490Medicaid
TX001019490Medicaid