Basic Information
| Provider Information | |||||||||
| NPI: | 1164404075 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHPM MISSION CARE CENTERS - NEW COVENANT LP | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GARDEN VILLA NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5420 W PLANO PKWY | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750934823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729313800 | ||||||||
| FaxNumber: | 9727676222 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 DEL NORTE DR | ||||||||
| Address2: | |||||||||
| City: | EL CAMPO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774372504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9795436762 | ||||||||
| FaxNumber: | 9795439626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 11/13/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLLIER | ||||||||
| AuthorizedOfficialFirstName: | JAMIE | ||||||||
| AuthorizedOfficialMiddleName: | LATTURE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 9727313800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 113790 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001013031 | 05 | TX | MEDICAID |