Healthcare Provider Details

I. General information

NPI: 1962435149
Provider Name (Legal Business Name): SALEM HOUSING CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 05/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W GIBSON ST
JASPER TX
75951-4903
US

IV. Provider business mailing address

5895 WINDWARD PKWY SUITE 200
ALPHARETTA GA
30005-5203
US

V. Phone/Fax

Practice location:
  • Phone: 409-384-5768
  • Fax: 409-383-1940
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 Number116446
License Number StateTX

VIII. Authorized Official

Name: DOUGLAS K. MITTLEIDER
Title or Position: PRESIDENT OF MGMT CO
Credential:
Phone: 770-619-0866