Provider Demographics
NPI:1578554309
Name:ST JOHNS EPISCOPAL RETIREMENT CORPORATION
Entity Type:Organization
Organization Name:ST JOHNS EPISCOPAL RETIREMENT CORPORATION
Other - Org Name:SEABURY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-333-2904
Mailing Address - Street 1:2443 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-2701
Mailing Address - Country:US
Mailing Address - Phone:432-333-2904
Mailing Address - Fax:432-333-6454
Practice Address - Street 1:2443 W 16TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-2701
Practice Address - Country:US
Practice Address - Phone:432-333-2904
Practice Address - Fax:432-333-6454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110426313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000501202Medicaid
TX675751Medicare ID - Type UnspecifiedMEDICARE PROVIDER #