Healthcare Provider Details

I. General information

NPI: 1891885943
Provider Name (Legal Business Name): THREE RIVERS NURSING HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 45TH ST.
THREE RIVERS TX
78071-2649
US

IV. Provider business mailing address

1717 45TH ST.
THREE RIVERS TX
78071-2649
US

V. Phone/Fax

Practice location:
  • Phone: 361-786-2256
  • Fax: 361-786-2456
Mailing address:
  • Phone: 361-786-2256
  • Fax: 361-786-2456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number112944
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number131278
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number136010
License Number StateTX

VIII. Authorized Official

Name: MR. RONALD L VIDRINE
Title or Position: OWNER
Credential:
Phone: 361-786-2256