Provider Demographics
NPI:1902993066
Name:AMBASSADOR HEALTH CARE OF BRADY INC
Entity Type:Organization
Organization Name:AMBASSADOR HEALTH CARE OF BRADY INC
Other - Org Name:HERITAGE DUVAL GARDENS
Other - Org Type:Other Name
Authorized Official - Title/Position:AR MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LOFTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-479-0766
Mailing Address - Street 1:1771 INTERNATIONAL PKWY
Mailing Address - Street 2:SUITE 121
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-1897
Mailing Address - Country:US
Mailing Address - Phone:972-479-0844
Mailing Address - Fax:
Practice Address - Street 1:5301 DUVAL RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-6618
Practice Address - Country:US
Practice Address - Phone:512-345-1805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108291314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4970Medicaid
TX675956Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER