Provider Demographics
NPI:1790842714
Name:EKKLESIA HEALTHCARE, LLC
Entity Type:Organization
Organization Name:EKKLESIA HEALTHCARE, LLC
Other - Org Name:AZALEA TRAIL NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-580-9424
Mailing Address - Street 1:PO BOX 2576
Mailing Address - Street 2:101 N. BRAZOS STREET
Mailing Address - City:WHITNEY
Mailing Address - State:TX
Mailing Address - Zip Code:76692-5576
Mailing Address - Country:US
Mailing Address - Phone:254-580-9424
Mailing Address - Fax:254-580-9892
Practice Address - Street 1:411 SPRING CREEK ROAD
Practice Address - Street 2:
Practice Address - City:GRAND SALINE
Practice Address - State:TX
Practice Address - Zip Code:75140
Practice Address - Country:US
Practice Address - Phone:903-962-4226
Practice Address - Fax:903-962-4492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118979314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001014774Medicaid
TX021897601Medicaid
TX021897601Medicaid
TX001014774Medicaid