Basic Information
| Provider Information | |||||||||
| NPI: | 1043465222 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAXIM HEALTHCARE SERVICES | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4444 CORONA DR STE 137 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784114323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618141455 | ||||||||
| FaxNumber: | 3618144066 | ||||||||
| Practice Location | |||||||||
| Address1: | 4444 CORONA DR STE 137 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784114323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618141455 | ||||||||
| FaxNumber: | 3618144066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2008 | ||||||||
| LastUpdateDate: | 12/01/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | IRVING | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINICAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3618141455 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MAXIM HEALTHCARE SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | R.N. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 376G00000X | 679391 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Related Providers | Nursing Home Administrator |
ID Information
| ID | Type | State | Issuer | Description | 521590951 | 01 | TX | TAX ID | OTHER |