Basic Information
| Provider Information | |||||||||
| NPI: | 1558747659 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRUENEPOINTE 1 ST. GILES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. GILES NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8502 HUEBNER RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782402466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107574987 | ||||||||
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| Practice Location | |||||||||
| Address1: | 950 CAMINO DEL REY | ||||||||
| Address2: | |||||||||
| City: | SOCORRO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799274288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107574987 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2015 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | DULLNIG | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2107574987 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001027118 | 05 | TX | MEDICAID | 145458 | 01 | TX | STATE LICENSE | OTHER |