Provider Demographics
NPI:1982886578
Name:HSMTX WATERTON PLAZA, LLC
Entity Type:Organization
Organization Name:HSMTX WATERTON PLAZA, LLC
Other - Org Name:THE WATERTON PLAZA SENIOR CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-934-7800
Mailing Address - Street 1:5300 HOLLISTER ST
Mailing Address - Street 2:SUITE 550
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77040-6137
Mailing Address - Country:US
Mailing Address - Phone:713-934-7800
Mailing Address - Fax:713-895-0064
Practice Address - Street 1:2875 SHILOH RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-2936
Practice Address - Country:US
Practice Address - Phone:903-561-1300
Practice Address - Fax:903-939-1754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001017767Medicaid
TX676193Medicare Oscar/Certification