Basic Information
| Provider Information | |||||||||
| NPI: | 1245427947 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRECKENRIDGE VILLAGE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | BRECKENRIDGE VILLAGE MALLARD HOUSE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15062 COUNTY ROAD 1145 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757047516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039568100 | ||||||||
| FaxNumber: | 9035968104 | ||||||||
| Practice Location | |||||||||
| Address1: | 15062 COUNTY ROAD 1145 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757047516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039568100 | ||||||||
| FaxNumber: | 9035968104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2007 | ||||||||
| LastUpdateDate: | 08/26/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9038968100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST CHILD & FAMILY SERVICES INC. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
No ID Information.