Basic Information
| Provider Information | |||||||||
| NPI: | 1295853844 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTURY FORT STOCKTON GEAC LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FORT STOCKTON NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 N SYCAMORE ST | ||||||||
| Address2: | |||||||||
| City: | FORT STOCKTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797354602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323367631 | ||||||||
| FaxNumber: | 4323368870 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 N SYCAMORE ST | ||||||||
| Address2: | |||||||||
| City: | FORT STOCKTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797354602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323367631 | ||||||||
| FaxNumber: | 4323368870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 06/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | SHELTON | ||||||||
| AuthorizedOfficialFirstName: | CHANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9404647018 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 112531 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 005310 | 05 | TX | MEDICAID |