Provider Demographics
NPI:1740277391
Name:CENTURY-EBONY LAKE-GEAC,LLC
Entity type:Organization
Organization Name:CENTURY-EBONY LAKE-GEAC,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER'S REPRESENTATIVE
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN,MS
Authorized Official - Phone:952-837-0818
Mailing Address - Street 1:1001 CENTRAL BLVD
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-7533
Mailing Address - Country:US
Mailing Address - Phone:956-541-0917
Mailing Address - Fax:956-541-2860
Practice Address - Street 1:1001 CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-7533
Practice Address - Country:US
Practice Address - Phone:956-541-0917
Practice Address - Fax:956-541-2860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112530314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX005259Medicaid
TX67-5635Medicare Oscar/Certification