Provider Demographics
NPI:1114950300
Name:HP SUNNYBROOK OF TEXAS INC
Entity Type:Organization
Organization Name:HP SUNNYBROOK OF TEXAS INC
Other - Org Name:SUNNYBROOK HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:MITTLEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-619-0866
Mailing Address - Street 1:925 N POINT PKWY
Mailing Address - Street 2:SUITE 440
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5210
Mailing Address - Country:US
Mailing Address - Phone:770-619-0866
Mailing Address - Fax:770-870-2892
Practice Address - Street 1:3050 SUNNYBROOK DRIVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78415-1797
Practice Address - Country:US
Practice Address - Phone:361-853-9981
Practice Address - Fax:361-853-1907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113261314000000X
GA651332BN1400X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4245Medicaid
TX4187490001Medicare NSC
67-5717Medicare ID - Type Unspecified