Basic Information
| Provider Information | |||||||||
| NPI: | 1427042217 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRACE CARE OF TEXAS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMMUNITY CARE CENTER OF CROCKETT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 E LOOP 304 | ||||||||
| Address2: | |||||||||
| City: | CROCKETT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365442051 | ||||||||
| FaxNumber: | 9365448605 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 E LOOP 304 | ||||||||
| Address2: | |||||||||
| City: | CROCKETT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365442051 | ||||||||
| FaxNumber: | 9365448605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCKAY | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9404426020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 114799 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004802 | 05 | TX | MEDICAID |