Basic Information
| Provider Information | |||||||||
| NPI: | 1518305952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNT MORIAH HEALTH AND REHABILITATION, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 NORTH ELM STREET | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403874388 | ||||||||
| FaxNumber: | 9403802410 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 FM 83 WEST | ||||||||
| Address2: | |||||||||
| City: | HEMPHILL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759488300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097875300 | ||||||||
| FaxNumber: | 4097875398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2013 | ||||||||
| LastUpdateDate: | 03/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9403874388 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 140842 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001021281 | 05 | TX | MEDICAID |