Basic Information
| Provider Information | |||||||||
| NPI: | 1861442469 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEWITT MEDICAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CORPUS CHRISTI NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W GOODWIN AVE | ||||||||
| Address2: | STE 600 | ||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779016502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615760694 | ||||||||
| FaxNumber: | 3615765484 | ||||||||
| Practice Location | |||||||||
| Address1: | 2735 AIRLINE ROAD | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3619920816 | ||||||||
| FaxNumber: | 3619920689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRITCHETT | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3612750504 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 118055 | TX | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 676107 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 361254101 | 05 | TX | MEDICAID | 5481 | 05 | TX | MEDICAID | 001026419 | 05 | TX | MEDICAID |