Basic Information
Provider Information | |||||||||
NPI: | 1992799886 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UVALDE COUNTY HOSPITAL AUTHORITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAN PEDRO MANOR | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1025 GARNER FIELD RD | ||||||||
Address2: |   | ||||||||
City: | UVALDE | ||||||||
State: | TX | ||||||||
PostalCode: | 788014809 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4699166100 | ||||||||
FaxNumber: | 4699166105 | ||||||||
Practice Location | |||||||||
Address1: | 515 W ASHBY PL | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782123802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2107325181 | ||||||||
FaxNumber: | 2107328663 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/07/2005 | ||||||||
LastUpdateDate: | 03/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURNAM | ||||||||
AuthorizedOfficialFirstName: | SOON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | TREASURER OF MANAGEMENT COMPANY | ||||||||
AuthorizedOfficialTelephone: | 9495401249 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   | TX | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 005211 | 05 | TX |   | MEDICAID |