Basic Information
| Provider Information | |||||||||
| NPI: | 1952305724 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FE DEERE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIVER RIDGE NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4838 HOLLY ROAD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784114753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3619917021 | ||||||||
| FaxNumber: | 3619919162 | ||||||||
| Practice Location | |||||||||
| Address1: | 3922 W RIVER DR | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784105725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617672000 | ||||||||
| FaxNumber: | 3617672006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 07/18/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEERE | ||||||||
| AuthorizedOfficialFirstName: | FRANCIS | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3619919021 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | F.E. DEERE INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 114209 | TX | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 114209 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 005351 | 05 | TX | MEDICAID |