Provider Demographics
NPI:1558472951
Name:KRISTI LEE MANOR INC
Entity Type:Organization
Organization Name:KRISTI LEE MANOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-728-5247
Mailing Address - Street 1:1941 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79512-3099
Mailing Address - Country:US
Mailing Address - Phone:325-728-5247
Mailing Address - Fax:325-728-2611
Practice Address - Street 1:1941 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:COLORADO CITY
Practice Address - State:TX
Practice Address - Zip Code:79512-3099
Practice Address - Country:US
Practice Address - Phone:325-728-5247
Practice Address - Fax:325-728-2611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111707313M00000X
TX676027314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45E123Medicaid
TX4345150001Medicare NSC
TX676027Medicare ID - Type Unspecified