Basic Information
| Provider Information | |||||||||
| NPI: | 1124053970 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HERMANN HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNIVERSITY PLACE NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 301208 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753031208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133384127 | ||||||||
| FaxNumber: | 7133384158 | ||||||||
| Practice Location | |||||||||
| Address1: | 7480 BEECHNUT ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770744502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135412900 | ||||||||
| FaxNumber: | 7133384158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 04/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | LARAWAY | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7132422707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 111656 | TX | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 314000000X | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001025488 | 05 | TX | MEDICAID |