Provider Demographics
NPI:1366496283
Name:KING'S MANOR METHODIST RETIREMENT SYSTEM, INC.
Entity Type:Organization
Organization Name:KING'S MANOR METHODIST RETIREMENT SYSTEM, INC.
Other - Org Name:KINGS MANOR METHODIST HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:OSBORN
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-364-0661
Mailing Address - Street 1:PO BOX 1999
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:TX
Mailing Address - Zip Code:79045-1999
Mailing Address - Country:US
Mailing Address - Phone:806-364-0661
Mailing Address - Fax:806-364-0675
Practice Address - Street 1:400 RANGER DR
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:TX
Practice Address - Zip Code:79045-2812
Practice Address - Country:US
Practice Address - Phone:806-364-0661
Practice Address - Fax:806-364-0675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4494313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000449403Medicaid