Provider Demographics
NPI:1376094284
Name:PONDEROSA NURSING AND REHABILIATION
Entity Type:Organization
Organization Name:PONDEROSA NURSING AND REHABILIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTATOR
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:LNFA
Authorized Official - Phone:903-667-2572
Mailing Address - Street 1:12520 FM 1840
Mailing Address - Street 2:
Mailing Address - City:DE KALB
Mailing Address - State:TX
Mailing Address - Zip Code:75559-1929
Mailing Address - Country:US
Mailing Address - Phone:903-667-2572
Mailing Address - Fax:
Practice Address - Street 1:12520 FM 1840
Practice Address - Street 2:
Practice Address - City:DE KALB
Practice Address - State:TX
Practice Address - Zip Code:75559-1929
Practice Address - Country:US
Practice Address - Phone:903-667-2572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX001021048314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001021048Medicaid