Basic Information
| Provider Information | |||||||||
| NPI: | 1447244116 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FANNIN COUNTY HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SOUTH PLACE REHABILITATION AND SKILLED NURSING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 WATERS RIDGE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LEWISVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750576011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728994401 | ||||||||
| FaxNumber: | 9728994460 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 GIBSON RD | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757515611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036775864 | ||||||||
| FaxNumber: | 9036775830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 07/17/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | SANDERSON | ||||||||
| AuthorizedOfficialFirstName: | CLARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BOARD PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9035831854 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 109683 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1028850 | 05 | TX | MEDICAID |