Basic Information
| Provider Information | |||||||||
| NPI: | 1568458305 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOLIDAY PINES NURSING AND REHABILITATION LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762014137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403874388 | ||||||||
| FaxNumber: | 9403802410 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 CARDINAL DR | ||||||||
| Address2: | |||||||||
| City: | WOODVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759795428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4092833397 | ||||||||
| FaxNumber: | 4092837564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 08/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | RICH | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| 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 | 115077 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001004233 | 05 | TX | MEDICAID | 094431603 | 01 | TX | TMHP DME CROSS-OVER | OTHER | 155126901 | 01 | TX | TMHP CROSS-OVER | OTHER |