Provider Demographics
NPI:1922088970
Name:LONG TERM CARE OF TEXAS, INC.
Entity Type:Organization
Organization Name:LONG TERM CARE OF TEXAS, INC.
Other - Org Name:LAKE VILLAGE NURSING & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:972-436-7571
Mailing Address - Street 1:169 LAKE PARK RD
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-2303
Mailing Address - Country:US
Mailing Address - Phone:972-436-7571
Mailing Address - Fax:972-221-4187
Practice Address - Street 1:169 LAKE PARK RD
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-2303
Practice Address - Country:US
Practice Address - Phone:972-436-7571
Practice Address - Fax:972-221-4187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113275314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX675560Medicare ID - Type UnspecifiedPROVIDER NUMBER