Basic Information
| Provider Information | |||||||||
| NPI: | 1356967624 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SLP ORANGE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PINEHURST NURSING AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 S UNIVERSITY DR STE 306 | ||||||||
| Address2: | |||||||||
| City: | FT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761075746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174107300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3000 CARDINAL ST | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776304737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098835727 | ||||||||
| FaxNumber: | 4098839078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2020 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | MISTRETTA | ||||||||
| AuthorizedOfficialFirstName: | CASSANDRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8174107300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.