Basic Information
Provider Information | |||||||||
NPI: | 1447478862 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MID-SOUTH NURSING HOMES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HUGULEY NURSING AND REHABILITATION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 602 COURTLAND ST | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328041360 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4079753000 | ||||||||
FaxNumber: | 4079753090 | ||||||||
Practice Location | |||||||||
Address1: | 301 HUGULEY BLVD | ||||||||
Address2: |   | ||||||||
City: | BURLESON | ||||||||
State: | TX | ||||||||
PostalCode: | 760287506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8175515900 | ||||||||
FaxNumber: | 8172932380 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2007 | ||||||||
LastUpdateDate: | 04/23/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEHTJE | ||||||||
AuthorizedOfficialFirstName: | RONALD | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | VP CFO | ||||||||
AuthorizedOfficialTelephone: | 4079753010 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 113805 | TX | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 000525805 | 05 | TX |   | MEDICAID | 021539402 | 05 | TX |   | MEDICAID |