Basic Information
Provider Information | |||||||||
NPI: | 1942818489 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SLP DIBOLL LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DIBOLL NURSING AND REHAB | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 900 S TEMPLE DR | ||||||||
Address2: |   | ||||||||
City: | DIBOLL | ||||||||
State: | TX | ||||||||
PostalCode: | 759412725 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9368295501 | ||||||||
FaxNumber: | 9368295503 | ||||||||
Practice Location | |||||||||
Address1: | 900 S TEMPLE DR | ||||||||
Address2: |   | ||||||||
City: | DIBOLL | ||||||||
State: | TX | ||||||||
PostalCode: | 759412725 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9368295501 | ||||||||
FaxNumber: | 9368295503 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2020 | ||||||||
LastUpdateDate: | 11/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MISTRETTA | ||||||||
AuthorizedOfficialFirstName: | CASSANDRA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8174107300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.