Basic Information
| Provider Information | |||||||||
| NPI: | 1336229798 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRENHAM HEALTH CARE LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRENHAM REST HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 NE LOOP 410 | ||||||||
| Address2: | SUITE #650 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782091204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108285686 | ||||||||
| FaxNumber: | 2108244669 | ||||||||
| Practice Location | |||||||||
| Address1: | 406 COTTONWOOD ST | ||||||||
| Address2: | |||||||||
| City: | BRENHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778333237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9798363434 | ||||||||
| FaxNumber: | 9798363461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 10/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | FELLBAUM | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2108285686 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 105157 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1528507-01 | 01 | TX | TMHP PROVIDER # | OTHER | 000415302 | 05 | TX | MEDICAID |