Provider Demographics
NPI:1588868905
Name:CISCO LONG TERM CARE, LLC
Entity type:Organization
Organization Name:CISCO LONG TERM CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LAIN
Authorized Official - Last Name:BYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-316-7790
Mailing Address - Street 1:526 TEXAS PT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-7738
Mailing Address - Country:US
Mailing Address - Phone:210-316-7790
Mailing Address - Fax:
Practice Address - Street 1:1404 FRONT ST
Practice Address - Street 2:
Practice Address - City:CISCO
Practice Address - State:TX
Practice Address - Zip Code:76437-3636
Practice Address - Country:US
Practice Address - Phone:254-442-4202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX675259Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER