Basic Information
| Provider Information | |||||||||
| NPI: | 1780149401 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LS QUITMAN OPERATOR LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HERITAGE HOUSE HEALTHCARE CENTRE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1026 E GOODE ST | ||||||||
| Address2: | |||||||||
| City: | QUITMAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757831641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037632284 | ||||||||
| FaxNumber: | 9037634301 | ||||||||
| Practice Location | |||||||||
| Address1: | 1026 E GOODE ST | ||||||||
| Address2: | |||||||||
| City: | QUITMAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757831641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037632284 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2019 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAZAR | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 3236511808 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.