Provider Demographics
NPI:1154362887
Name:TEAKWOOD MANOR, LLC
Entity type:Organization
Organization Name:TEAKWOOD MANOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:F
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-692-8977
Mailing Address - Street 1:4723 TAFT BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-5001
Mailing Address - Country:US
Mailing Address - Phone:940-692-8977
Mailing Address - Fax:940-692-8567
Practice Address - Street 1:1003 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:TX
Practice Address - Zip Code:79553-6825
Practice Address - Country:US
Practice Address - Phone:325-773-3671
Practice Address - Fax:325-773-5751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117297314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4930OtherVENDOR NUMBER
TX67-5769Medicare ID - Type Unspecified