Provider Demographics
NPI:1851729560
Name:CHARLESTON DFW OPERATIONS LLC
Entity Type:Organization
Organization Name:CHARLESTON DFW OPERATIONS LLC
Other - Org Name:DFW NURSING & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-439-6600
Mailing Address - Street 1:127 W BROAD ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-4297
Mailing Address - Country:US
Mailing Address - Phone:337-439-6600
Mailing Address - Fax:337-439-6647
Practice Address - Street 1:900 W LEUDA ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3002
Practice Address - Country:US
Practice Address - Phone:337-439-6600
Practice Address - Fax:337-439-6647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX136289314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004002Medicaid
TX001025543Medicaid
TX4002Medicaid
TX4002Medicaid