Provider Demographics
NPI:1740270651
Name:BRENTWOOD HEALTHCARE, LTD
Entity type:Organization
Organization Name:BRENTWOOD HEALTHCARE, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES 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 3
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:214-388-0424
Practice Address - Fax:214-381-4454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110094314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112772201Medicaid
TX094685702Medicaid
TXHO6757027Medicaid
TX000514806Medicaid
TX000514806Medicaid
TXHO6757027Medicaid