Basic Information
| Provider Information | |||||||||
| NPI: | 1053710376 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAYLOR COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ADVANCED REHABILITATION AND HEALTHCARE OF WICHITA FALLS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4810 KEMP BLVD | ||||||||
| Address2: | |||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9407660281 | ||||||||
| FaxNumber: | 9407234935 | ||||||||
| Practice Location | |||||||||
| Address1: | 4810 KEMP BLVD | ||||||||
| Address2: | |||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9407660281 | ||||||||
| FaxNumber: | 9407234935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2014 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARDIN | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9408895572 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004742 | 05 | TX | MEDICAID |