Provider Demographics
NPI:1255043683
Name:SHALOM LIVING CENTER LLC
Entity type:Organization
Organization Name:SHALOM LIVING CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATILDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-658-4662
Mailing Address - Street 1:4895 GARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-2736
Mailing Address - Country:US
Mailing Address - Phone:409-658-4662
Mailing Address - Fax:
Practice Address - Street 1:4895 GARWOOD LN
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-2736
Practice Address - Country:US
Practice Address - Phone:409-658-4662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty