Provider Demographics
NPI:1821081977
Name:VILLA HAVEN HEALTH & REHABILITATION CENTER
Entity Type:Organization
Organization Name:VILLA HAVEN HEALTH & REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LAKE
Authorized Official - Last Name:DEGRAND
Authorized Official - Suffix:
Authorized Official - Credentials:SNF ADMINISTRATOR
Authorized Official - Phone:254-559-3386
Mailing Address - Street 1:300 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:76424-4804
Mailing Address - Country:US
Mailing Address - Phone:254-559-3386
Mailing Address - Fax:254-559-7259
Practice Address - Street 1:300 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:TX
Practice Address - Zip Code:76424-4804
Practice Address - Country:US
Practice Address - Phone:254-559-3386
Practice Address - Fax:254-559-7259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX004773314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========Medicare UPIN