Basic Information
| Provider Information | |||||||||
| NPI: | 1982033585 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FANNIN COUNTY HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LONGMEADOW HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 W SAM HOUSTON PKWY N | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770415161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324676000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 120 MEADOW VIEW DR | ||||||||
| Address2: | |||||||||
| City: | JUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762479639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406482731 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2013 | ||||||||
| LastUpdateDate: | 07/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | SANTORO | ||||||||
| AuthorizedOfficialFirstName: | KELLE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | SR DIRECTOR AR | ||||||||
| AuthorizedOfficialTelephone: | 8324675728 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1028707 | 05 | TX | MEDICAID |