1841254174 NPI number — DEWITT MEDICAL DISTRICT

Table of content: (NPI 1841254174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841254174 NPI number — DEWITT MEDICAL DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEWITT MEDICAL DISTRICT
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:
KINGSVILLE NURSING AND REHABILITATION CENTER
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:
1841254174
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 W GOODWIN AVE
Provider Second Line Business Mailing Address:
STE 600
Provider Business Mailing Address City Name:
VICTORIA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77901-6502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-576-0694
Provider Business Mailing Address Fax Number:
361-576-5484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3130 S BRAHMA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78363-7257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-592-8700
Provider Business Practice Location Address Fax Number:
361-592-3030
Provider Enumeration Date:
04/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PRITCHETT
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
361-275-0504

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  115826 , 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: 675815 , 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: 360973701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 539801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: HH076S . This is a "BCBS BLUELINK" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 001026483 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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