Basic Information
Provider Information | |||||||||
NPI: | 1972581882 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEARTWAY III CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AVALON PLACE-WHARTON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1405 VALHALLA DR | ||||||||
Address2: |   | ||||||||
City: | WHARTON | ||||||||
State: | TX | ||||||||
PostalCode: | 774889218 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9795321244 | ||||||||
FaxNumber: | 9795321142 | ||||||||
Practice Location | |||||||||
Address1: | 1405 VALHALLA DR | ||||||||
Address2: |   | ||||||||
City: | WHARTON | ||||||||
State: | TX | ||||||||
PostalCode: | 774889218 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9795321244 | ||||||||
FaxNumber: | 9795321142 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OBERGFELL | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | T. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT, BOARD OF DIRECTORS | ||||||||
AuthorizedOfficialTelephone: | 2147770282 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 112200 | TX | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.