Provider Demographics
NPI:1912982083
Name:PRAIRIE ACRES
Entity Type:Organization
Organization Name:PRAIRIE ACRES
Other - Org Name:FRIONA HERITAGE ESTATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRISTER
Authorized Official - Suffix:
Authorized Official - Credentials:LNFA
Authorized Official - Phone:806-250-3922
Mailing Address - Street 1:201 E. 15TH STREET
Mailing Address - Street 2:
Mailing Address - City:FRIONA
Mailing Address - State:TX
Mailing Address - Zip Code:79035
Mailing Address - Country:US
Mailing Address - Phone:806-250-3922
Mailing Address - Fax:806-250-2132
Practice Address - Street 1:201 E. 15TH STREET
Practice Address - Street 2:
Practice Address - City:FRIONA
Practice Address - State:TX
Practice Address - Zip Code:79035
Practice Address - Country:US
Practice Address - Phone:806-250-3922
Practice Address - Fax:806-250-2132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107250310400000X
TX126276310400000X
TX111644313M00000X
TX125044313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
1280270001OtherMEDICARE DMERC
TX021936201Medicaid
TX000509501Medicaid
TX001001908Medicaid
1280270001OtherMEDICARE DMERC