Provider Demographics
NPI:1710140173
Name:THE VILLAGE AT GLEANNLOCH FARMS, INC
Entity Type:Organization
Organization Name:THE VILLAGE AT GLEANNLOCH FARMS, INC
Other - Org Name:THE VILLAGE AT GLEANNLOCH FARMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF HEALTH SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:TAB
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WERNER
Authorized Official - Suffix:
Authorized Official - Credentials:LNFA
Authorized Official - Phone:281-430-4941
Mailing Address - Street 1:9505 NORTHPOINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-3799
Mailing Address - Country:US
Mailing Address - Phone:281-430-4941
Mailing Address - Fax:281-430-4907
Practice Address - Street 1:9505 NORTHPOINTE BLVD
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-3799
Practice Address - Country:US
Practice Address - Phone:281-430-4941
Practice Address - Fax:281-430-4907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX127078310400000X
TX126881314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001017154Medicaid