Basic Information
| Provider Information | |||||||||
| NPI: | 1295777902 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST 380 NURSING CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | TRINTY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2108 15TH STREET | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406835023 | ||||||||
| FaxNumber: | 9406833184 | ||||||||
| Practice Location | |||||||||
| Address1: | 2108 15TH ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406835023 | ||||||||
| FaxNumber: | 9406833184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 07/30/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OWENS | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN OF BOARD | ||||||||
| AuthorizedOfficialTelephone: | 9406835283 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 001014008 | 05 | TX | MEDICAID |