Basic Information
| Provider Information | |||||||||
| NPI: | 1578554309 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST JOHNS EPISCOPAL RETIREMENT CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SEABURY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2443 W 16TH ST | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797632701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323332904 | ||||||||
| FaxNumber: | 4323336454 | ||||||||
| Practice Location | |||||||||
| Address1: | 2443 W 16TH ST | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797632701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323332904 | ||||||||
| FaxNumber: | 4323336454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2005 | ||||||||
| LastUpdateDate: | 01/20/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | COLLEEN | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4323332904 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 110426 | TX | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 000501202 | 05 | TX | MEDICAID |