Provider Demographics
NPI:1033169636
Name:TRINITY MISSION OF GRANBURY, LLC
Entity Type:Organization
Organization Name:TRINITY MISSION OF GRANBURY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-937-7994
Mailing Address - Street 1:600 REUNION CT
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-1610
Mailing Address - Country:US
Mailing Address - Phone:817-573-3773
Mailing Address - Fax:817-573-0103
Practice Address - Street 1:600 REUNION CT
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-1610
Practice Address - Country:US
Practice Address - Phone:817-573-3773
Practice Address - Fax:817-573-0103
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT DOVE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116586314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001001875Medicaid
675084Medicare Oscar/Certification