Basic Information
Provider Information | |||||||||
NPI: | 1689851461 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HMG PARK MANOR OF WESTWOOD, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WESTWOOD MANOR | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1780 HUGHES LANDING BLVD STE 500 | ||||||||
Address2: |   | ||||||||
City: | THE WOODLANDS | ||||||||
State: | TX | ||||||||
PostalCode: | 773804009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2814195520 | ||||||||
FaxNumber: | 2814195527 | ||||||||
Practice Location | |||||||||
Address1: | 5015 SW 28TH ST | ||||||||
Address2: |   | ||||||||
City: | TOPEKA | ||||||||
State: | KS | ||||||||
PostalCode: | 666142319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7852730886 | ||||||||
FaxNumber: | 7852730959 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2008 | ||||||||
LastUpdateDate: | 06/14/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DASPIT | ||||||||
AuthorizedOfficialFirstName: | LAURENCE | ||||||||
AuthorizedOfficialMiddleName: | C. | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2814195520 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/14/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N089019 | KS | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 200557040C | 05 | KS |   | MEDICAID |