Provider Demographics
NPI:1851743637
Name:LTC OF FALL CREEK LLC
Entity Type:Organization
Organization Name:LTC OF FALL CREEK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHARLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:THREADGILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-482-8242
Mailing Address - Street 1:200 CONGRESS AVE
Mailing Address - Street 2:SUITE 30A
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-4527
Mailing Address - Country:US
Mailing Address - Phone:512-482-8242
Mailing Address - Fax:
Practice Address - Street 1:14949 MESA DR
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-2952
Practice Address - Country:US
Practice Address - Phone:281-902-4152
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2017-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001027972Medicaid