Basic Information
| Provider Information | |||||||||
| NPI: | 1043217375 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHEAT NURSING HOME INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALICEVILLE MANOR NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 703 17TH ST NW | ||||||||
| Address2: | |||||||||
| City: | ALICEVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354421426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053736307 | ||||||||
| FaxNumber: | 2053732737 | ||||||||
| Practice Location | |||||||||
| Address1: | 703 17TH ST NW | ||||||||
| Address2: | |||||||||
| City: | ALICEVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354421426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053736307 | ||||||||
| FaxNumber: | 2053732737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 04/30/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHEAT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | EVAN | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2053736307 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LNHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 4754610S | AL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4754610S | 05 | AL | MEDICAID |