Provider Demographics
NPI:1932112554
Name:ST. JOSEPH MANOR
Entity Type:Organization
Organization Name:ST. JOSEPH MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:COTTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-821-7330
Mailing Address - Street 1:2333 MANOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-1907
Mailing Address - Country:US
Mailing Address - Phone:979-821-7330
Mailing Address - Fax:979-821-7301
Practice Address - Street 1:2333 MANOR DRIVE
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-1907
Practice Address - Country:US
Practice Address - Phone:979-821-7330
Practice Address - Fax:979-821-7301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114596313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001000504Medicaid
TX001000504Medicaid