Provider Demographics
NPI:1104956366
Name:GENERATION GROUP HOME
Entity type:Organization
Organization Name:GENERATION GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:COKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:512-926-6813
Mailing Address - Street 1:5605 BERKMAN DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-2622
Mailing Address - Country:US
Mailing Address - Phone:512-926-6813
Mailing Address - Fax:512-926-3730
Practice Address - Street 1:5605 BERKMAN DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-2622
Practice Address - Country:US
Practice Address - Phone:512-926-6813
Practice Address - Fax:512-926-3730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX050603310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001002999Medicaid