Provider Demographics
NPI:1790309482
Name:MG AL GRAND PRAIRIE LLC
Entity Type:Organization
Organization Name:MG AL GRAND PRAIRIE LLC
Other - Org Name:MAYBERRY GARDENS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-213-8135
Mailing Address - Street 1:3272 N GARLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75040-3207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:540 E POLO RD BLDG 3
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3503
Practice Address - Country:US
Practice Address - Phone:972-975-9044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-29
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility