Basic Information
| Provider Information | |||||||||
| NPI: | 1043206345 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOODVILLE HEALTH CARE CENTER LTD. CO | ||||||||
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| OtherOrganizationName: | WOODVILLE HEALTH AND REHAB CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2537 GOLDEN BEAR DR | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750062377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149544114 | ||||||||
| FaxNumber: | 2148713057 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 N BEECH ST | ||||||||
| Address2: | |||||||||
| City: | WOODVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759794718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149544114 | ||||||||
| FaxNumber: | 2148713057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 08/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | UNDERHILL | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 2149544114 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 314000000X | 108626 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 155861101 | 05 | TX | MEDICAID | 000465204 | 05 | TX | MEDICAID | 022621901 | 05 | TX | MEDICAID |