Basic Information
| Provider Information | |||||||||
| NPI: | 1821081977 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLA HAVEN HEALTH & REHABILITATION CENTER | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | BRECKENRIDGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764244804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2545593386 | ||||||||
| FaxNumber: | 2545597259 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | BRECKENRIDGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764244804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2545593386 | ||||||||
| FaxNumber: | 2545597259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DEGRAND | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | LAKE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2545593386 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | SNF ADMINISTRATOR | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 004773 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.