Basic Information
| Provider Information | |||||||||
| NPI: | 1669771366 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMITY FELLOWSERVE OF MIDLAND, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KISSITO HEALTHCARE MIDLAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5228 VALLEYPOINTE PKWY | ||||||||
| Address2: | BLDG. B, SUITE 1 | ||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240193074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402650322 | ||||||||
| FaxNumber: | 5402650305 | ||||||||
| Practice Location | |||||||||
| Address1: | 3203 SAGE ST | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797055711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326835403 | ||||||||
| FaxNumber: | 4326825105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2011 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | CLARKE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5402650322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMITY FELLOWSERVE, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 132737 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001019588 | 05 | TX | MEDICAID | 004280 | 01 | TX | FAC. ID | OTHER |