Basic Information
| Provider Information | |||||||||
| NPI: | 1013981794 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEW GRAHAM OAKS CARE CENTER INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 1ST ST | ||||||||
| Address2: | |||||||||
| City: | GRAHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764503603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405498787 | ||||||||
| FaxNumber: | 9940549557 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 1ST ST | ||||||||
| Address2: | |||||||||
| City: | GRAHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764503603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405498787 | ||||||||
| FaxNumber: | 9940549557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILLMETH | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9405498787 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | L.N.F.A | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 114203 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 5241 | 01 | TX | VENDER NUMBER | OTHER |