1558368993 NPI number — ROBERTSON COUNTY NURSING HOME, INC.

Table of content: (NPI 1558368993)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558368993 NPI number — ROBERTSON COUNTY NURSING HOME, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERTSON COUNTY NURSING HOME, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CALVERT NURSING HOME
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558368993
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3801 WOODSIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76016-3030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-654-3042
Provider Business Mailing Address Fax Number:
817-446-3666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 E BROWNING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALVERT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77837-7593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-364-2391
Provider Business Practice Location Address Fax Number:
979-364-2798
Provider Enumeration Date:
06/30/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KILLIAN
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
817-654-3042

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  108535 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4365 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".