Organization
SUBTENANT 3611 DICKASON AVENUE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RAYMOND C OBORN (REGIONAL VP OF OPERATIONS)
(949) 240-7200
Entity
Organization
Contact information
Practice address
3611 DICKASON AVENUE, DALLAS, TX 75219-4912
(214) 559-0140
(214) 559-0171
Mailing address
3611 DICKASON AVENUE, DALLAS, TX 75219-4912
(214) 559-0140
(214) 559-0171
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
130513
TX
314000000X
Skilled Nursing Facility
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
001019490
—
TX
Enumeration date
08/30/2007
Last updated
10/10/2011
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