Provider Demographics
NPI:1134113947
Name:FANNIN COUNTY HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:FANNIN COUNTY HOSPITAL AUTHORITY
Other - Org Name:HERITAGE PLAZA NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:DENVER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-583-1854
Mailing Address - Street 1:1500 WATERS RIDGE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-6011
Mailing Address - Country:US
Mailing Address - Phone:972-899-4401
Mailing Address - Fax:972-899-4460
Practice Address - Street 1:600 W 52ND ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2980
Practice Address - Country:US
Practice Address - Phone:903-792-6700
Practice Address - Fax:903-792-6216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109167314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1028769Medicaid
TX148993201OtherMEDICAID CO B
AZ675561Medicare Oscar/Certification
TX148993201OtherMEDICAID CO B