# SHADY OAK NURSING AND REHABILITATION, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1780681643
- **Authorized official:** MR. BYRON M BURRIS II LNFA (PRESIDENT)
- **Authorized official phone:** (361) 576-9454

## Contact information

- **Practice address:** 101 SOUTH LANCASTER, MOULTON, TX 77975-0120
- **Practice address phone:** (361) 596-7373
- **Practice address fax:** (361) 596-7671
- **Mailing address:** PO BOX 7230, VICTORIA, TX 77903-7230
- **Mailing address phone:** (361) 576-9454
- **Mailing address fax:** (361) 576-2994

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 111107 | TX | Yes |

## Other

- **Enumeration date:** 07/06/2005
- **Last updated:** 11/05/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 001012451 | — | TX |
| 05 | — | 171961901 | — | TX |
| 05 | — | 171961902 | — | TX |
| 05 | — | 4627 | — | TX |