Provider Demographics
NPI:1043613748
Name:DECATUR HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:DECATUR HOSPITAL AUTHORITY
Other - Org Name:RIDGMAR MEDICAL LODGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:L
Authorized Official - Last Name:WREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-627-5921
Mailing Address - Street 1:6600 LANDS END CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-2100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6600 LANDS END CT
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-2100
Practice Address - Country:US
Practice Address - Phone:817-665-1971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-08
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX67-6101OtherMEDICARE CCN