1114081619 NPI number — LIFECARE HOME NURSING, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114081619 NPI number — LIFECARE HOME NURSING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFECARE HOME NURSING, LLC
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:
Provider Other Organization Name Type Code:
6
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:
1114081619
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1905 NE STALLINGS DR STE 5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NACOGDOCHES
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75961-3805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-560-3500
Provider Business Mailing Address Fax Number:
936-560-3505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2618 NORTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NACOGDOCHES
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75965-3501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-560-3500
Provider Business Practice Location Address Fax Number:
936-560-3505
Provider Enumeration Date:
12/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILCOX
Authorized Official First Name:
AMY
Authorized Official Middle Name:
LYNETTE
Authorized Official Title or Position:
ADMINISTRATOR / CEO
Authorized Official Telephone Number:
903-297-9300

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0068227 , 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: 162528703 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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