Basic Information
| Provider Information | |||||||||
| NPI: | 1962435149 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SALEM HOUSING CORPORATION | ||||||||
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| OtherOrganizationName: | TIMBERLAKE HEALTH AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5895 WINDWARD PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300055203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706190866 | ||||||||
| FaxNumber: | 7708702892 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 W GIBSON ST | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759514903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4093845768 | ||||||||
| FaxNumber: | 4093831940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 05/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | MITTLEIDER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF MGMT CO | ||||||||
| AuthorizedOfficialTelephone: | 7706190866 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 116446 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001013913 | 05 | TX | MEDICAID |