Basic Information
Provider Information | |||||||||
NPI: | 1437117272 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LIBERTY COUNTY HOSPITAL DISTRICT NO. 1 | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PINE TREE LODGE NURSING CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4150 INTERNATIONAL PLAZA | ||||||||
Address2: | SUITE 600 | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761094831 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8173488959 | ||||||||
FaxNumber: | 8173480466 | ||||||||
Practice Location | |||||||||
Address1: | 2711 PINE TREE RD. | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | TX | ||||||||
PostalCode: | 756041646 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9037593994 | ||||||||
FaxNumber: | 9037591439 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2006 | ||||||||
LastUpdateDate: | 02/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STRATTON | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: | BRUCE | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9363367422 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 111739 | TX | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 001004827 | 05 | TX |   | MEDICAID | 004989 | 01 | TX | MEDICAID VENDOR # | OTHER | 165860101 | 05 | TX |   | MEDICAID |