Basic Information
| Provider Information | |||||||||
| NPI: | 1841374238 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MT VERNON NURSING HOME INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MISSION MANOR NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 YATES ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754573233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035374424 | ||||||||
| FaxNumber: | 9035373427 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 YATES ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754573233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035374424 | ||||||||
| FaxNumber: | 9035373427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 12/28/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POWELL | ||||||||
| AuthorizedOfficialFirstName: | PAM | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9035374424 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | L.N.F.A. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 117687 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000465902 | 05 | TX | MEDICAID |