Basic Information
Provider Information | |||||||||
NPI: | 1851578892 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SEARS CAPROCK RETIREMENT CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MESA SPRINGS HEALTHCARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 VILLAGE DR | ||||||||
Address2: | SUITE 400 | ||||||||
City: | ABILENE | ||||||||
State: | TX | ||||||||
PostalCode: | 796068231 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3256915519 | ||||||||
FaxNumber: | 3256984582 | ||||||||
Practice Location | |||||||||
Address1: | 7171 BUFFALO GAP | ||||||||
Address2: |   | ||||||||
City: | ABILENE | ||||||||
State: | TX | ||||||||
PostalCode: | 796065450 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3256915519 | ||||||||
FaxNumber: | 3256984582 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/22/2008 | ||||||||
LastUpdateDate: | 08/01/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JOHNSON | ||||||||
AuthorizedOfficialFirstName: | NANCY | ||||||||
AuthorizedOfficialMiddleName: | S. | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT/CFO | ||||||||
AuthorizedOfficialTelephone: | 3256915519 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X |   |   | N |   | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |   | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 001015958 | 05 | TX |   | MEDICAID |