Basic Information
Provider Information | |||||||||
NPI: | 1912081241 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PINNACLE HEALTH FACILITIES XVII LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GRANGER NURSING AND REHABILITATION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5420 W PLANO PKWY | ||||||||
Address2: |   | ||||||||
City: | PLANO | ||||||||
State: | TX | ||||||||
PostalCode: | 750934823 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9729313800 | ||||||||
FaxNumber: | 9727676222 | ||||||||
Practice Location | |||||||||
Address1: | 2001 KENNEDY ST | ||||||||
Address2: |   | ||||||||
City: | GRANGER | ||||||||
State: | IA | ||||||||
PostalCode: | 501099746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5159992588 | ||||||||
FaxNumber: | 5159992442 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2006 | ||||||||
LastUpdateDate: | 08/03/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COLLIER | ||||||||
AuthorizedOfficialFirstName: | JAMIE | ||||||||
AuthorizedOfficialMiddleName: | LATTURE | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
AuthorizedOfficialTelephone: | 9729313800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   | IA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 0809814 | 05 | IA |   | MEDICAID |