Basic Information
Provider Information | |||||||||
NPI: | 1104098458 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAMPSTAND HEALTH & REHAB OF BRYAN, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAMPSTAND HEALTH & REHAB OF BRYAN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2723 SUMMER OAKS DR | ||||||||
Address2: |   | ||||||||
City: | BARTLETT | ||||||||
State: | TN | ||||||||
PostalCode: | 381342858 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9019377994 | ||||||||
FaxNumber: | 9019371516 | ||||||||
Practice Location | |||||||||
Address1: | 2001 E 29TH ST | ||||||||
Address2: |   | ||||||||
City: | BRYAN | ||||||||
State: | TX | ||||||||
PostalCode: | 778021954 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9798226611 | ||||||||
FaxNumber: | 9798226699 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2008 | ||||||||
LastUpdateDate: | 07/24/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MURPHY | ||||||||
AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9019377994 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | DESCENDING DOVE, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
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 | 001016041 | 05 | TX |   | MEDICAID |