Basic Information
| Provider Information | |||||||||
| NPI: | 1124070511 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OAKBEND MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVALON PLACE--WHARTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1705 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774693246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813414881 | ||||||||
| FaxNumber: | 2813413056 | ||||||||
| Practice Location | |||||||||
| Address1: | 1405 VALHALLA DR | ||||||||
| Address2: | |||||||||
| City: | WHARTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774889218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9795321244 | ||||||||
| FaxNumber: | 9795321142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 02/17/2017 | ||||||||
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| AuthorizedOfficialLastName: | FREUDENBERGER | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2813414881 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 112200 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 5227 | 05 | TX | MEDICAID |