Provider Demographics
NPI:1174678023
Name:CONNIE'S ASSISTED LIVING HOME OF BEN HUR
Entity Type:Organization
Organization Name:CONNIE'S ASSISTED LIVING HOME OF BEN HUR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:LAREE
Authorized Official - Last Name:HAMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-789-2296
Mailing Address - Street 1:980 FM 339 S
Mailing Address - Street 2:
Mailing Address - City:GROESBECK
Mailing Address - State:TX
Mailing Address - Zip Code:76642-5519
Mailing Address - Country:US
Mailing Address - Phone:254-789-2296
Mailing Address - Fax:254-789-2276
Practice Address - Street 1:980 FM 339 S
Practice Address - Street 2:
Practice Address - City:GROESBECK
Practice Address - State:TX
Practice Address - Zip Code:76642-5519
Practice Address - Country:US
Practice Address - Phone:254-789-2296
Practice Address - Fax:254-789-2276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000403310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001013307Medicaid
TX001013306Medicaid