Healthcare Provider Details

I. General information

NPI: 1578554309
Provider Name (Legal Business Name): ST JOHNS EPISCOPAL RETIREMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2005
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2443 W 16TH ST
ODESSA TX
79763-2701
US

IV. Provider business mailing address

2443 W 16TH ST
ODESSA TX
79763-2701
US

V. Phone/Fax

Practice location:
  • Phone: 432-333-2904
  • Fax: 432-333-6454
Mailing address:
  • Phone: 432-333-2904
  • Fax: 432-333-6454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number110426
License Number StateTX

VIII. Authorized Official

Name: MRS. COLLEEN J. SMITH
Title or Position: ASSISTANT ADMINISTRATOR
Credential:
Phone: 432-333-2904