Basic Information
| Provider Information | |||||||||
| NPI: | 1831574227 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRUENEPOINTE 1 KERENS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | KERENS CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8502 HUEBNER RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782402466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107574987 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 809 NE 4TH ST | ||||||||
| Address2: | |||||||||
| City: | KERENS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751442715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033063211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2015 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DULLNIG | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDET | ||||||||
| AuthorizedOfficialTelephone: | 2107574987 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | APPLIED FOR | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001027111 | 05 | TX | MEDICAID | 145333 | 01 | TX | STATE LICENSE | OTHER |