Basic Information
| Provider Information | |||||||||
| NPI: | 1811949456 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SLP HAMLIN LLC | ||||||||
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| OtherOrganizationName: | HOMEPLACE MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 S. UNIVERSITY DR. | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174107300 | ||||||||
| FaxNumber: | 8174236270 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 SW AVENUE F | ||||||||
| Address2: | |||||||||
| City: | HAMLIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 795204615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3255763643 | ||||||||
| FaxNumber: | 3255763913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 08/25/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/25/2006 | ||||||||
| NPIReactivationDate: | 11/15/2006 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEONARD | ||||||||
| AuthorizedOfficialFirstName: | JOSHUA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/COO | ||||||||
| AuthorizedOfficialTelephone: | 8174107300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004399 | 01 | TX | FACILITY ID NO. | OTHER |