Basic Information
| Provider Information | |||||||||
| NPI: | 1639535131 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TYLER COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE BRADFORD AT BROOKSIDE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 W BLUFF ST | ||||||||
| Address2: | |||||||||
| City: | WOODVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759794738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4092836400 | ||||||||
| FaxNumber: | 4092835961 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 W PARK | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773518151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9363285021 | ||||||||
| FaxNumber: | 9363285022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2016 | ||||||||
| LastUpdateDate: | 01/13/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WRIGHT | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | GAYLE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4092834600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN, ED.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 142698 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.