Provider Demographics
NPI:1861445397
Name:SLP JEFFREY PLACE LLC
Entity Type:Organization
Organization Name:SLP JEFFREY PLACE LLC
Other - Org Name:JEFFREY PLACE HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MISTRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-410-7300
Mailing Address - Street 1:1300 S UNIVERSITY DR STE 306
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-5746
Mailing Address - Country:US
Mailing Address - Phone:817-410-7300
Mailing Address - Fax:
Practice Address - Street 1:820 JEFFREY ST
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4745
Practice Address - Country:US
Practice Address - Phone:254-772-9480
Practice Address - Fax:254-772-2885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2019-08-22
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
TX004776OtherFACILITY ID NO.
TX001026280Medicaid
TX001026280Medicaid