Basic Information
| Provider Information | |||||||||
| NPI: | 1497211437 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HAMILTON COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BRODIE RANCH NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 FRATE BARKER RD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787483614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124445627 | ||||||||
| FaxNumber: | 5123682034 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 FRATE BARKER RD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787483614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124445627 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2019 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURNAM | ||||||||
| AuthorizedOfficialFirstName: | SOON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER OF MANAGEMENT COMPANY | ||||||||
| AuthorizedOfficialTelephone: | 9495401249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 104451 | 05 | TX | MEDICAID | 5586 | 05 | TX | MEDICAID | 001030444 | 05 | TX | MEDICAID |