Provider Demographics
NPI:1649253303
Name:SEARS BRAZOS RETIREMENT CORPORATION
Entity type:Organization
Organization Name:SEARS BRAZOS RETIREMENT CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/ASST. CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSSWHTE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:325-691-5519
Mailing Address - Street 1:1 VILLAGE DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-8231
Mailing Address - Country:US
Mailing Address - Phone:325-691-5519
Mailing Address - Fax:325-698-4582
Practice Address - Street 1:1700 WOODGATE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8600
Practice Address - Country:US
Practice Address - Phone:254-666-5454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113492311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX67-6211OtherMEDICARE SNF
TX001012296Medicaid