Basic Information
| Provider Information | |||||||||
| NPI: | 1902856685 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRINITY MISSION OF DIBOLL, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TRINITY MISSION HEALTH & REHAB OF DIBOLL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2723 SUMMER OAKS DR | ||||||||
| Address2: | |||||||||
| City: | BARTLETT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381342858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9019377994 | ||||||||
| FaxNumber: | 9019371516 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 S TEMPLE DR | ||||||||
| Address2: | |||||||||
| City: | DIBOLL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759412725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9368295501 | ||||||||
| FaxNumber: | 9368295503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 07/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | MURPHY | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9019377994 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COVENANT DOVE, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 114018 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001001923 | 05 | TX | MEDICAID |