Basic Information
| Provider Information | |||||||||
| NPI: | 1114950300 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HP SUNNYBROOK OF TEXAS INC | ||||||||
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| OtherOrganizationName: | SUNNYBROOK HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 925 N POINT PKWY | ||||||||
| Address2: | SUITE 440 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300055210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706190866 | ||||||||
| FaxNumber: | 7708702892 | ||||||||
| Practice Location | |||||||||
| Address1: | 3050 SUNNYBROOK DRIVE | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784151797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618539981 | ||||||||
| FaxNumber: | 3618531907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 11/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | MITTLEIDER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7706190866 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BN1400X | 651 | GA | N | Suppliers | Durable Medical Equipment & Medical Supplies | Nursing Facility Supplies | 332BP3500X | 651 | GA | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 314000000X | 113261 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4245 | 05 | TX | MEDICAID |