Basic Information
| Provider Information | |||||||||
| NPI: | 1750376273 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOODLAND SPRINGS NURSING CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EVENTIDE NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 W HIGHWAY 6 | ||||||||
| Address2: | SUITE 509 | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767127923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543996788 | ||||||||
| FaxNumber: | 2543996766 | ||||||||
| Practice Location | |||||||||
| Address1: | 1405 W STOREY ST | ||||||||
| Address2: | |||||||||
| City: | SAN SABA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 768776422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543725112 | ||||||||
| FaxNumber: | 2543725114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 01/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | BUMPASS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | JAY | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2543996788 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LNHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 114176 | TX | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 140720701 | 05 | TX | MEDICAID |