Basic Information
| Provider Information | |||||||||
| NPI: | 1487641973 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBUS NURSING AND REHABILITATION LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 401 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762014137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403874388 | ||||||||
| FaxNumber: | 9403802410 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 SWEETBRIAR DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 789343005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9797325716 | ||||||||
| FaxNumber: | 9797326020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 10/26/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RICH | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9403874388 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 109362 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 155174901 | 01 | TX | TMHP (CROSS-OVER) | OTHER | 001004351 | 05 | TX | MEDICAID |