Healthcare Provider Details

I. General information

NPI: 1982691226
Provider Name (Legal Business Name): VIDOR MANOR NURSING HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 MOORE DR
VIDOR TX
77662-3843
US

IV. Provider business mailing address

470 MOORE DR
VIDOR TX
77662-3843
US

V. Phone/Fax

Practice location:
  • Phone: 409-769-2454
  • Fax: 409-769-9324
Mailing address:
  • Phone: 409-769-2454
  • Fax: 409-769-9324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number114895
License Number StateTX

VIII. Authorized Official

Name: JANICE PITA
Title or Position: INSURANCE/MEDICARE
Credential:
Phone: 580-622-6300