Provider Demographics
NPI:1417358474
Name:NATIONAL NURSING & REHAB DALLAS, LLC
Entity type:Organization
Organization Name:NATIONAL NURSING & REHAB DALLAS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-822-2654
Mailing Address - Street 1:85 NE LOOP 410
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-5866
Mailing Address - Country:US
Mailing Address - Phone:210-822-0475
Mailing Address - Fax:210-822-0485
Practice Address - Street 1:14114 DALLAS PKWY
Practice Address - Street 2:SUITE 670
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-4325
Practice Address - Country:US
Practice Address - Phone:972-716-9937
Practice Address - Fax:972-716-9961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-09
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX016730251E00000X, 251J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX357625801Medicaid
TX357625801Medicaid