Provider Demographics
NPI:1770928434
Name:EAST TEXAS AZALEA OPERATING COMPANY LLC
Entity type:Organization
Organization Name:EAST TEXAS AZALEA OPERATING COMPANY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:POWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-534-0523
Mailing Address - Street 1:1901 RICKETY LN
Mailing Address - Street 2:SUITE 208
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1702
Mailing Address - Country:US
Mailing Address - Phone:903-534-0523
Mailing Address - Fax:903-534-4705
Practice Address - Street 1:810 S PORTER AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2300
Practice Address - Country:US
Practice Address - Phone:903-593-2463
Practice Address - Fax:903-597-1203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001021267Medicaid
TX675912Medicare PIN