Healthcare Provider Details

I. General information

NPI: 1114950300
Provider Name (Legal Business Name): HP SUNNYBROOK OF TEXAS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 SUNNYBROOK DRIVE
CORPUS CHRISTI TX
78415-1797
US

IV. Provider business mailing address

925 N POINT PKWY SUITE 440
ALPHARETTA GA
30005-5210
US

V. Phone/Fax

Practice location:
  • Phone: 361-853-9981
  • Fax: 361-853-1907
Mailing address:
  • Phone: 770-619-0866
  • Fax: 770-870-2892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number113261
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number651
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number651
License Number StateGA

VIII. Authorized Official

Name: DOUGLAS K MITTLEIDER
Title or Position: PRESIDENT
Credential:
Phone: 770-619-0866