Provider Demographics
NPI:1215286547
Name:CHARTER HEALTHCARE OF SAN ANTONIO, LLC
Entity type:Organization
Organization Name:CHARTER HEALTHCARE OF SAN ANTONIO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-644-4965
Mailing Address - Street 1:2819 NW LOOP 410 STE C
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-5105
Mailing Address - Country:US
Mailing Address - Phone:210-979-9933
Mailing Address - Fax:210-979-9932
Practice Address - Street 1:2819 NW LOOP 410 STE C
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230
Practice Address - Country:US
Practice Address - Phone:210-979-9933
Practice Address - Fax:210-979-9932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-31
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111751704Medicaid