Basic Information
| Provider Information | |||||||||
| NPI: | 1669477147 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOLLAND LAKE NURSING CENTER LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 122267 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761212267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175980160 | ||||||||
| FaxNumber: | 8175980162 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 HOLLAND LAKE DR | ||||||||
| Address2: | |||||||||
| City: | WEATHERFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760865851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175980160 | ||||||||
| FaxNumber: | 8175980162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAYES | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8175980160 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 113174 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.