Provider Demographics
NPI:1518305952
Name:MOUNT MORIAH HEALTH AND REHABILITATION, LLC
Entity Type:Organization
Organization Name:MOUNT MORIAH HEALTH AND REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-387-4388
Mailing Address - Street 1:401 NORTH ELM STREET
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201
Mailing Address - Country:US
Mailing Address - Phone:940-387-4388
Mailing Address - Fax:940-380-2410
Practice Address - Street 1:355 FM 83 WEST
Practice Address - Street 2:
Practice Address - City:HEMPHILL
Practice Address - State:TX
Practice Address - Zip Code:75948-8300
Practice Address - Country:US
Practice Address - Phone:409-787-5300
Practice Address - Fax:409-787-5398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-07
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX140842314000000X
TX5654314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001021281Medicaid
676344Medicare Oscar/Certification