Provider Demographics
NPI:1821574856
Name:ROBERT W. LEISKE LEGACY CENTERS, INC.
Entity Type:Organization
Organization Name:ROBERT W. LEISKE LEGACY CENTERS, INC.
Other - Org Name:COUNTRY CLUB RETIREMENT COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ECORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-328-9828
Mailing Address - Street 1:745 N BUCKNER BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-2786
Mailing Address - Country:US
Mailing Address - Phone:214-328-9828
Mailing Address - Fax:214-328-9828
Practice Address - Street 1:4773 FM 933 N
Practice Address - Street 2:
Practice Address - City:WHITNEY
Practice Address - State:TX
Practice Address - Zip Code:76692-4713
Practice Address - Country:US
Practice Address - Phone:214-328-9828
Practice Address - Fax:214-328-3042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103976310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103976Medicaid