Healthcare Provider Details

I. General information

NPI: 1386936664
Provider Name (Legal Business Name): MSHC BONNER STREET PLAZA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 S BONNER ST
JACKSONVILLE TX
75766-2330
US

IV. Provider business mailing address

421 BONNER STREET
JACKSONVILLE TX
75766-2330
US

V. Phone/Fax

Practice location:
  • Phone: 903-586-9871
  • Fax:
Mailing address:
  • Phone: 903-586-9871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number129146
License Number StateTX

VIII. Authorized Official

Name: CARLA POWER
Title or Position: CFO
Credential:
Phone: 903-792-0838