Provider Demographics
NPI:1447244116
Name:FANNIN COUNTY HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:FANNIN COUNTY HOSPITAL AUTHORITY
Other - Org Name:SOUTH PLACE REHABILITATION AND SKILLED NURSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERSON
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 1:150 GIBSON RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-5611
Practice Address - Country:US
Practice Address - Phone:903-677-5864
Practice Address - Fax:903-677-5830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109683314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1028850Medicaid
TX154721801OtherMEDICAID CO B
AZ455834Medicare Oscar/Certification
TX154721801OtherMEDICAID CO B