Provider Demographics
NPI:1700875705
Name:BRENTWOOD HEALTHCARE, LTD
Entity Type:Organization
Organization Name:BRENTWOOD HEALTHCARE, LTD
Other - Org Name:BRENTWOOD PLACE ONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DICK
Authorized Official - Middle Name:
Authorized Official - Last Name:STEBBINS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:903-757-5360
Mailing Address - Street 1:600 E WHALEY ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6525
Mailing Address - Country:US
Mailing Address - Phone:903-757-5360
Mailing Address - Fax:903-236-7036
Practice Address - Street 1:3505 S BUCKNER BLVD BLDG 2
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-5451
Practice Address - Country:US
Practice Address - Phone:214-388-0609
Practice Address - Fax:214-388-2643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110323314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000512607Medicaid
TX112772202Medicaid
TX022675501Medicaid
TXHO6756803Medicaid
TXHO6756803Medicaid