Provider Demographics
NPI:1043436298
Name:ADVANCED LIVING TECHNOLOGIES INC
Entity type:Organization
Organization Name:ADVANCED LIVING TECHNOLOGIES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-345-0700
Mailing Address - Street 1:10415 MORADO CIR
Mailing Address - Street 2:SUITE 3 120
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5696
Mailing Address - Country:US
Mailing Address - Phone:512-345-0700
Mailing Address - Fax:888-368-3534
Practice Address - Street 1:710 HIGHWAY 359 SOUTH
Practice Address - Street 2:
Practice Address - City:BROOKSHIRE
Practice Address - State:TX
Practice Address - Zip Code:77423-0638
Practice Address - Country:US
Practice Address - Phone:281-375-5272
Practice Address - Fax:281-375-5383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1160763140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000450102Medicaid
TX675700Medicare ID - Type Unspecified