Provider Demographics
NPI:1730305988
Name:ADVANCED LIVING TECHNOLOGIES INC
Entity Type:Organization
Organization Name:ADVANCED LIVING TECHNOLOGIES INC
Other - Org Name:STOCKDALE NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-345-0700
Mailing Address - Street 1:10415 MORADO CIR
Mailing Address - Street 2:BUILDING 3 SUITE 120
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5696
Mailing Address - Country:US
Mailing Address - Phone:512-345-0700
Mailing Address - Fax:888-368-3534
Practice Address - Street 1:300 W SALMON STREET
Practice Address - Street 2:
Practice Address - City:STOCKDALE
Practice Address - State:TX
Practice Address - Zip Code:78160-0039
Practice Address - Country:US
Practice Address - Phone:830-996-3721
Practice Address - Fax:830-996-3355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117222314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000427703Medicaid
TX000427703Medicaid