Healthcare Provider Details

I. General information

NPI: 1174769483
Provider Name (Legal Business Name): CLEBURNE COUNTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 02/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2485 S. MAJOR DRIVE
BEAUMONT TX
77707-5019
US

IV. Provider business mailing address

4500 MAIN AVE
GROVES TX
77619-4712
US

V. Phone/Fax

Practice location:
  • Phone: 409-861-4611
  • Fax:
Mailing address:
  • Phone: 409-962-0910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateTX

VIII. Authorized Official

Name: MR. JAMES W MOORE SR.
Title or Position: PRESIDENT
Credential:
Phone: 409-962-0910