NPIMap

Organization Active NPI

Providence Park, Inc.

Doing business as Ascension Living Providence Village

  • Skilled Nursing Facility
  • Waco, TX
National Provider Identifier
1720086655
Registry record updated Jun 23, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
108085 Issued in TX
Legal business name
PROVIDENCE PARK, INC.
Doing business as
Ascension Living Providence Village
Practice address
300 W Highway 6
Waco, TX 76712-4041
Phone
(254) 761-8500
Fax
(254) 761-8050
NPI assigned
Jul 13, 2005
Last updated
Jun 23, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 23, 2025

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

Authorized official

Name
Erin Shadbolt
Title
Ceo
Phone
(314) 729-3500

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Nursing Facility/Intermediate Care Facility 313M00000X 108085 TX
Skilled Nursing Facility 314000000X 108085 TX Primary

Addresses

Primary practice location

300 W Highway 6
Waco, TX 76712-4041

Mailing address

300 W Highway 6
Waco, TX 76712-4041
Phone (254) 761-8500

Other identifiers 3

IdentifierTypeStateIssuer
000530801MedicaidTX
HH2907OtherBLUE CROSS BLUE SHIELD
001026977MedicaidTX

Other names 2

  • Ascension Living Providence Village Doing business as
  • St. Catherine Center Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150918002016 TX Part A Provider - Skilled Nursing Facility 0749597045 Practice locations: Waco, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1720086655. Details of each certification follow.

Skilled nursing facility certification: CCN 455983

Legal name
PROVIDENCE PARK INC
Doing business as
ASCENSION LIVING PROVIDENCE VILLAGE
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF distinct part
Participating since
Jan 3, 1992
Last certification
Feb 26, 2025
Beds
225 (165 certified)
Ownership / control type
Nonprofit Corporation
Multi-facility organization
Ascension Living
Organization structure
CorporationNon-profit
Incorporated
Mar 25, 2015 in TX
Enrollment address
300 West Highway 6
Waco, TX 76712-4041
Nursing home name
ST. CATHERINE CENTER
Affiliated entity
ASCENSION LIVING

Care Compare: Nursing home

Medicare Care Compare
Listed as
St. Catherine CenterCCN 455983 · All quality measures
Overall star rating
5 of 5
Health inspections
4 of 5
Staffing
5 of 5
Quality measures
2 of 5
Type
Medicare and Medicaid
Ownership
Non profit - Corporation
Certified
Jan 3, 1992
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
165143.9 residents per day on average
Chain
Ascension Living12 facilities in the chain
Penalties (3 years)
1Fines totaling $13,065

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
45D1050456Saint Catherine Center Laboratory300 W Highway 6, Waco, TX 76712Certificate of waiverFeb 2, 2028

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 9

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Medical Solutions LLC Organization, Omaha, NE Corporation, LLC, Medical staffing company Adp of the SNF Jun 14, 2017
Health Dimensions Consulting Inc Organization, Minneapolis, MN Corporation, Medical staffing company Adp of the SNF Aug 2, 2019
Darrell R Pietsch Individual Operational/Managerial Control Aug 1, 2017
Adp of the SNF Aug 1, 2017
Amy K Lefco Individual Operational/Managerial Control Feb 17, 2025
Adp of the SNF Feb 17, 2025
Ascension Health Senior Care Organization, Saint Louis, MO Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jul 1, 2014 100%
Adp of the SNF Jul 1, 2015
Ryan Breedlove Individual Corporate DirectorVP Post Acute & at Home Jan 1, 2024
Adp of the SNF Jan 1, 2024
Lisa Musgrave Individual Corporate DirectorSVP Post Acute Care Jan 1, 2024
Adp of the SNF Jan 1, 2024
Kenneth Smoot Individual Corporate DirectorChief Mission Integrations Officer Jan 1, 2024
Adp of the SNF Jan 1, 2024
Erin Shadbolt Individual Corporate OfficerChief Executive Officer Feb 28, 2023
Adp of the SNF Jan 1, 2024

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 13

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 13

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1121212800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750636800000",
    "number": "1720086655",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 W HIGHWAY 6",
            "city": "WACO",
            "state": "TX",
            "postal_code": "767124041",
            "telephone_number": "254-761-8500",
            "fax_number": "254-761-8050"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "300 W HIGHWAY 6",
            "city": "WACO",
            "state": "TX",
            "postal_code": "767124041",
            "telephone_number": "254-761-8500",
            "fax_number": "254-761-8050"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE PARK, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-13",
        "last_updated": "2025-06-23",
        "certification_date": "2025-06-23",
        "status": "A",
        "authorized_official_last_name": "SHADBOLT",
        "authorized_official_first_name": "ERIN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "314-729-3500"
    },
    "taxonomies": [
        {
            "code": "313M00000X",
            "taxonomy_group": "",
            "desc": "Nursing Facility/Intermediate Care Facility",
            "state": "TX",
            "license": "108085",
            "primary": false
        },
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "TX",
            "license": "108085",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000530801",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "HH2907",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "001026977",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ascension Living Providence Village",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Ascension Living Providence Village",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "St. Catherine Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Waco, TX

Sources for this page

Verify at the official NPI Registry.