Mystic Park SCC LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

Legal business name

MYSTIC PARK SCC LLC

Doing business as

Mystic Park Nursing & Rehab Center

Practice address

8503 Mystic Park
San Antonio, TX 78254-2544

Phone

(210) 256-0906

Fax

(210) 256-0925

NPI assigned

Dec 29, 2014

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Michael Beal

Title

Chief Executive Officer

Phone

(214) 252-7600

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Mystic Park Nursing & Rehab Center Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1419811200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1583193600000",
    "number": "1336537398",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "600 N PEARL ST STE 1050",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752017495",
            "telephone_number": "214-252-7600",
            "fax_number": "214-252-7704"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8503 MYSTIC PARK",
            "city": "SAN ANTONIO",
            "state": "TX",
            "postal_code": "782542544",
            "telephone_number": "210-256-0906",
            "fax_number": "210-256-0925"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MYSTIC PARK SCC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-12-29",
        "last_updated": "2020-03-03",
        "certification_date": "2020-03-03",
        "status": "A",
        "authorized_official_last_name": "BEAL",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "214-252-7600"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "TX",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "001026539",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VENDORID/FACILITY ID",
            "identifier": "5447 101669",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mystic Park Nursing & Rehab Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Mystic Park Nursing & Rehab Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Skilled Nursing Facility in San Antonio, TX
• Providers in San Antonio, TX by specialty
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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 3, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.