Basic Information
| Provider Information | |||||||||
| NPI: | 1861445397 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SLP JEFFREY PLACE LLC | ||||||||
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| OtherOrganizationName: | JEFFREY PLACE HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 S UNIVERSITY DR STE 306 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761075746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174107300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 820 JEFFREY ST | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767104745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547729480 | ||||||||
| FaxNumber: | 2547722885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | MISTRETTA | ||||||||
| AuthorizedOfficialFirstName: | CASSANDRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8174107300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004776 | 01 | TX | FACILITY ID NO. | OTHER |