Provider Demographics
NPI:1619918489
Name:SAN JUAN NURSING HOME, INC.
Entity Type:Organization
Organization Name:SAN JUAN NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELOISA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-787-1771
Mailing Address - Street 1:300 N. NEBRASKA AVE.
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589
Mailing Address - Country:US
Mailing Address - Phone:956-787-1771
Mailing Address - Fax:956-787-8091
Practice Address - Street 1:300 N NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-3040
Practice Address - Country:US
Practice Address - Phone:956-787-1771
Practice Address - Fax:956-787-8091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX144386314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000454002Medicaid
TX45D0665204OtherCLIA
TX144386OtherTEXAS DEPARTMENT OF AGING AND DISABILITIES
TX455484Medicare ID - Type UnspecifiedMEDICARE
TX0381320001Medicare NSC