Provider Demographics
NPI:1720003536
Name:LEGEND OAKS - SAN ANGELO, LLC
Entity Type:Organization
Organization Name:LEGEND OAKS - SAN ANGELO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-564-0100
Mailing Address - Street 1:5455 KNICKERBOCKER RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-7711
Mailing Address - Country:US
Mailing Address - Phone:325-944-1600
Mailing Address - Fax:325-944-1660
Practice Address - Street 1:5455 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7711
Practice Address - Country:US
Practice Address - Phone:325-944-1600
Practice Address - Fax:325-944-1660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5472314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
676100Medicare ID - Type Unspecified