1710140173 NPI number — THE VILLAGE AT GLEANNLOCH FARMS, INC

Table of content: (NPI 1710140173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710140173 NPI number — THE VILLAGE AT GLEANNLOCH FARMS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE VILLAGE AT GLEANNLOCH FARMS, 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:
THE VILLAGE AT GLEANNLOCH FARMS
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:
1710140173
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9505 NORTHPOINTE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77379-3799
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-430-4941
Provider Business Mailing Address Fax Number:
281-430-4907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9505 NORTHPOINTE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77379-3799
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-430-4941
Provider Business Practice Location Address Fax Number:
281-430-4907
Provider Enumeration Date:
07/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WERNER
Authorized Official First Name:
TAB
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
DIRECTOR OF HEALTH SERVICES
Authorized Official Telephone Number:
281-430-4941

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  127078 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 126881 , 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: 001017154 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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