Basic Information
| Provider Information | |||||||||
| NPI: | 1366402430 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMONT NURSING HOME, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX Q | ||||||||
| Address2: | |||||||||
| City: | PREMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783750260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3613483553 | ||||||||
| FaxNumber: | 3613483596 | ||||||||
| Practice Location | |||||||||
| Address1: | 431 N.W. 3RD STREET | ||||||||
| Address2: | |||||||||
| City: | PREMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3613483553 | ||||||||
| FaxNumber: | 3613483596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCCLEERY | ||||||||
| AuthorizedOfficialFirstName: | RANDI | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3613483553 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 4487 | TX | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.