Basic Information
| Provider Information | |||||||||
| NPI: | 1396798583 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACK COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAITH COMMUNITY NURSING & REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 MAGNOLIA ST | ||||||||
| Address2: | |||||||||
| City: | JACKSBORO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764581111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405676633 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 211 E JASPER ST | ||||||||
| Address2: | |||||||||
| City: | JACKSBORO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764581848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405672686 | ||||||||
| FaxNumber: | 9405675038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 06/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEAMAN | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9405676633 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004888 | 01 | TX | FACILITY ID NO. | OTHER | 001026254 | 05 | TX | MEDICAID |