Basic Information
Provider Information | |||||||||
NPI: | 1942298146 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MCLENNAN COUNTY NURSING HOME | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | QUALITY CARE OF WACO | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 E WHALEY ST | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | TX | ||||||||
PostalCode: | 756016525 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9037575360 | ||||||||
FaxNumber: | 9037538621 | ||||||||
Practice Location | |||||||||
Address1: | 2501 MAPLE AVE | ||||||||
Address2: |   | ||||||||
City: | WACO | ||||||||
State: | TX | ||||||||
PostalCode: | 767071337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2547523571 | ||||||||
FaxNumber: | 2547522005 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2005 | ||||||||
LastUpdateDate: | 09/13/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STEBBINS | ||||||||
AuthorizedOfficialFirstName: | DICK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT OF THE GENERAL PARTNER | ||||||||
AuthorizedOfficialTelephone: | 9037575360 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 004837 | TX | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | HO4554787 | 05 | TX |   | MEDICAID | 000483703 | 05 | TX |   | MEDICAID | 111339102 | 05 | TX |   | MEDICAID | 111339101 | 05 | TX |   | MEDICAID |