Basic Information
| Provider Information | |||||||||
| NPI: | 1225117419 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JORDAN & GILLIS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | THE HERITAGE NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1026 E GOODE ST | ||||||||
| Address2: | |||||||||
| City: | QUITMAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757831641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037632284 | ||||||||
| FaxNumber: | 9037634301 | ||||||||
| Practice Location | |||||||||
| Address1: | 1026 E GOODE ST | ||||||||
| Address2: | |||||||||
| City: | QUITMAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757831641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037632284 | ||||||||
| FaxNumber: | 9037634301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 02/07/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROLEN | ||||||||
| AuthorizedOfficialFirstName: | RHONDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9037632284 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LNFA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 000410803 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4108 | 05 | TX | MEDICAID |