Provider Demographics
NPI:1598751166
Name:INDEPENDENT ORDER OF ODD FELLOWS GRAND LODGE 100F OF TEXAS
Entity Type:Organization
Organization Name:INDEPENDENT ORDER OF ODD FELLOWS GRAND LODGE 100F OF TEXAS
Other - Org Name:ODD FELLOW AND REBEKAH NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GRAND SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:CURTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-872-7438
Mailing Address - Street 1:2300 S OAK GROVE RD
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-6841
Mailing Address - Country:US
Mailing Address - Phone:972-875-8643
Mailing Address - Fax:972-875-1179
Practice Address - Street 1:2300 S OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-6841
Practice Address - Country:US
Practice Address - Phone:972-875-8643
Practice Address - Fax:972-875-1179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114389313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000456001Medicaid
TX190096101Medicaid
TX000456001Medicaid