Basic Information
| Provider Information | |||||||||
| NPI: | 1275992638 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIO AT FOX HOLLOW, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1020 WILLIAM WAY NW | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373124369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233884614 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 310 AMERICA DRIVE | ||||||||
| Address2: | |||||||||
| City: | BROWNSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107574987 | ||||||||
| FaxNumber: | 2107574987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2016 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DULLNIG | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2105044309 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | IN PROCESS | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 145090 | 01 | STATE LICENSE | OTHER | 001027609 | 05 | TX | MEDICAID |