Basic Information
| Provider Information | |||||||||
| NPI: | 1356328215 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEARTWAY III CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AVALON PLACE - KIRBYVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 700 N HERNDON AVE | ||||||||
| Address2: | |||||||||
| City: | KIRBYVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759561518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4094236111 | ||||||||
| FaxNumber: | 4094235807 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 N HERNDON AVE | ||||||||
| Address2: | |||||||||
| City: | KIRBYVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759561518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4094236111 | ||||||||
| FaxNumber: | 4094235807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OBERGFELL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT-BOARD OF DIRECTORS | ||||||||
| AuthorizedOfficialTelephone: | 2147770282 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 112142 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.