Provider Demographics
NPI:1689951543
Name:ROCK CREEK HEALTH AND REHABILITATION LLC
Entity Type:Organization
Organization Name:ROCK CREEK HEALTH AND REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-387-4388
Mailing Address - Street 1:401 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-4137
Mailing Address - Country:US
Mailing Address - Phone:940-387-4388
Mailing Address - Fax:940-380-2410
Practice Address - Street 1:1414 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-3431
Practice Address - Country:US
Practice Address - Phone:903-439-0107
Practice Address - Fax:903-439-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-07
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX295239201OtherMEDICAID CO B CROSS-OVER
TX001020121Medicaid
TX001020121Medicaid