Healthcare Provider Details

I. General information

NPI: 1790842714
Provider Name (Legal Business Name): EKKLESIA HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 SPRING CREEK ROAD
GRAND SALINE TX
75140
US

IV. Provider business mailing address

PO BOX 2576 101 N. BRAZOS STREET
WHITNEY TX
76692-5576
US

V. Phone/Fax

Practice location:
  • Phone: 903-962-4226
  • Fax: 903-962-4492
Mailing address:
  • Phone: 254-580-9424
  • Fax: 254-580-9892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number118979
License Number StateTX

VIII. Authorized Official

Name: MRS. PATRICIA DIANE WARD
Title or Position: PRESIDENT
Credential:
Phone: 254-580-9424