Provider Demographics
NPI:1578804233
Name:BANNOCKBURN GROUP, LLC
Entity Type:Organization
Organization Name:BANNOCKBURN GROUP, LLC
Other - Org Name:RALLS NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-771-0272
Mailing Address - Street 1:11006 GENOA AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-3838
Mailing Address - Country:US
Mailing Address - Phone:806-771-0272
Mailing Address - Fax:806-771-0272
Practice Address - Street 1:1111 AVENUE P
Practice Address - Street 2:
Practice Address - City:RALLS
Practice Address - State:TX
Practice Address - Zip Code:79357-3502
Practice Address - Country:US
Practice Address - Phone:806-253-2596
Practice Address - Fax:806-253-2749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0000314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX675407Medicare Oscar/Certification