Provider Demographics
NPI:1770630626
Name:WESTWARD TRAILS OPERATOR LLC
Entity Type:Organization
Organization Name:WESTWARD TRAILS OPERATOR LLC
Other - Org Name:WESTWARD TRAILS HEALTH AND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-569-2631
Mailing Address - Street 1:3001 WESTWARD DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75964-1232
Mailing Address - Country:US
Mailing Address - Phone:936-569-2631
Mailing Address - Fax:936-569-0590
Practice Address - Street 1:3001 WESTWARD DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75964-1232
Practice Address - Country:US
Practice Address - Phone:936-569-2631
Practice Address - Fax:936-569-0590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX133763314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX005305OtherFACILITY ID
TX001014556Medicaid
TX001014556Medicaid